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AN  INQUIRY  INTO  THE 

PRINCIPLES  OF  TREATMENT  OF 

BROKEN  LIMBS 


FRONTISPIECE 

The  frontispiece  is  from  a  photograph  showing  a  subject  in 
position  upon  the  author's  apparatus  for  use  in  applying  an  im- 
movable splint  to  a  fracture  of  the  shaft  of  the  femur. 

The  photograph  was  taken  in  1873  before  the  days  of  offi- 
cially known  trained  nurses  and  has  historical  value. 

The  seated  assistant  is  the  skilled  and  noted  "Orderly  of 
Ward  16." 

It  will  be  observed  that  the  anaesthetized  patient  has  only 
been  moved  crosswise  of  his  bed.  He  has  been  spared  the  chance 
of  serious  accident  in  being  moved  from  his  bed  to  the  operating- 
table  as  in  the  procedure  shown  in  Plate  V.  The  patient  is  so 
placed  that  there  is  no  obstacle  to  his  freest  surgical  functioning^ 
by  which  is  meant  that  his  position  upon  the  apparatus  imposes 
no  restrictions  upon  the  use  of  medical  or  surgical  measures  of 
relief  for  which  sudden  need  might  arise.  The  capacity  for 
extended  surgical  functioning  may  be  compared  with  the  re- 
strictions imposed  by  the  use  of  apparatus  shown  in  Plate  V, 
By  one  who,  like  the  author,  has  seen  sudden  demands  made 
upon  the  skill  of  the  operator  to  meet  the  occurrence  of  serious 
accidents  the  difference  in  attitude  of  the  patient  for  surgical 
functioning  will  be  appreciated. 

The  author's  method  tends  to  forestall  the  occurrence  of  such 
accidents  and  affords  the  best  conditions  for  their  treatment 
should  they  arise.  The  procedure,  by  averting  a  disturbance  of 
the  injured  soft  parts,  also  tends  to  obviate  swelling  of  the  limb, 
an  objectionable  complication  in  the  application  of  the  splint. 

The  patient  has  only  been  shifted  in  position  on  his  own  bed, 
and  may  very  well  in  case  of  accident  be  treated  upon  the  ap- 
paratus, or,  he  may  be  easily  returned  in  a  few  seconds'  time  to 
his  original  position  in  bed. 


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I  '  i:  I  \' 


AN  INQUIRY 

INTO    THE 

PRINCIPLES  OF  TREATMENT 

OF 

BROKEN  LIMBS 

J    PHILOSOPHICO-SURGICAL   ESSAY 
WITH   SURGICAL  NOTES 


BY 

WILLIAM  F.   FLUHRER,    M.D. 

OONStTLTIKQ  SURGKON  TO   BBLLEVUB   AND   MOUNT  SINAI   BOSPITAM 


NEW    YORK 

REBMAN    COMPANY 

141  West  36th  Street 


Copyright,  1916,  by 

WILLIAM    F.    FLUHRER 

New   York 


PBIKTED  IK  AMERICA 


PREFACE 

Soon  after  the  author  had  invented  the  method  of 
rapidly  immobilizing  broken  bones  by  the  use  of  per- 
forated narrow  tin  strips,  he  explained  the  procedure 
with  the  aid  of  photographic  illustrations,  to  a  dis- 
guished  physician  from  a  distant  city.  His  response 
was:  "What  does  Professor  Blank  [naming  an  emi- 
nent surgeon]  say  of  the  merit  of  the  method?"  I 
then  realized  that  it  was  not  enough  to  devise  an  im- 
provement of  existing  procedure  but  that  it  was  also 
important  to  prove  its  value  independent  of  the  dic- 
tum of  personal  authority. 

In  the  following  pages  I  have  endeavored  to  sub- 
stitute impersonal  proof  of  values  in  place  of  the 
pronouncements  of  personal  authority  or  the  expres- 
sions of  consensus  of  opinion.  The  furthest  reach 
of  personal  authority,  often  derived  from  adventi- 
tious circumstance,  is  to  cast  a  presumption  in  favor 
of  or  against  the  correctness  of  a  stated  conclusion. 

Some  years  ago  in  the  discussion  of  a  paper  read 
before  the  Academy  of  Medicine  on  the  non-operative 
treatment  of  recent  simple  fractures  of  the  patella  the 
writer  was  one  of  a  small  minority  speaking  in  favor 
of  the  open  method  of  suturing.  The  eminent  author 
of  the  paper  of  the  evening  in  closing  the  debate,  de- 
clared he  would  be  governed  in  his  action  by  the  prac- 
tice of  the  most  distinguished  surgeons  throughout 
the  world  and  the  consensus  of  opinion  as  expressed 
in  surgical  societies.    In  the  field  of  empirical  prac- 


VI  PREFACE 

tice  no  better  rule  of  conduct  could  be  formulated: 
in  scientific  practice,  however,  in  the  writer's  judg- 
ment, the  conclusions  determining  the  conduct  of  the 
surgeon  should  not  be  influenced  by  personal  author- 
ity or  consensus  of  opinion. 

In  his  advocacy  of  the  open  method  of  wiring 
simple  fractures  of  the  patella  the  writer  said:  "The 
value  of  a  method  of  treatment  is  not  to  be  deter- 
mined by  reference  to  the  fluctuating  standard  of 
professional  opinion  but  by  the  comparison  of  the  re- 
sults of  treatment  to  a  single  and  invariable  standard 
of  perfection."  (See  N,  Y,  Medical  Record,  June 
14,  1890.) 

In  this  essay  small  increments  of  variations,  even 
though  sometimes  derived  from  a  consideration  of 
obsolete  and  discarded  procedures  of  treatment,  are 
studied  for  the  purpose  of  determining  the  trend  of 
the  embodied  principles  toward  a  theoretical  maxi- 
mum of  excellence. 

In  laying  the  foundation  of  impersonal  proof  of 
value  of  methods  of  treatment,  the  author  has  seen 
fit  to  reduce  his  argument  to  syllogistic  form. 

With  a  common  interest  he  has  sought  to  pro- 
ceed hand  in  hand  with  his  reader  in  this  investiga- 
tion of  a  particular  phase  of  truth. 


CONTENTS 

PAGE 

A.  Concrete  Subject-matter  .         -         -         .         l 

B.  Abstract  Considerations  -         -         -         -       6S 


SURGICAL  NOTES 

I.     Septic  Saturation  of  Bellevue  Hospital  in  the 

Seventies.     Battle  Against  Sepsis        -         -       79 

II.  The  Open  Operation  in  the  Treatment  of 
Simple  Fractures  Considered  in  its  Relation 
to  the  Assertion  of  a  Negative  -  -       90 

III.  Treatment   of  Septic   Wound    Complications — 

Compound  Fractures  and  Primary  Amputations     102 

IV.  Scope  or   Degree   of   Extension   Considered  in 

Reference  to  Principles   Embodied  in  Surgi- 
cal Procedures    -  -  -  -  -         -110 

Index      - 123 


LIST   OF   ILLUSTRATIONS 

Patient  on  apparatus  in  the  application  of  a  plaster-of- 
Paris  splint  to  a  fracture  of  the  shaft  of  the  femur 

Frontispiece 

ITG.  PAGE 

1.  A   diagrammatic    representation   of    a    truss    in    the 
median  longitudinal  plane  of  the  leg  in  a  fracture  of 

the    tibia    q 

2.  Plan  of  cutting  blanket  covering  of  thigh  in  fracture 

of  shaft  of  the  femur 27 

3.  Ground  plan  of  the  position  of  the  patient  upon  ap- 
paratus for  setting  a  fracture  of  the  femur 30 

4.  Construction  of  the  pelvic  portion  of  the  thigh  splint, 
rear    view    3g 

5.  Hand  crochet-drill  and  fork Ill 

6.  Use  of  fork  in  placing  loop  of  silk  in  notch  of  the 
crochet-drill    112 

7.  Drilling  of  an  irregular  fracture  of  the  patella  while 

the  knee-joint  is  extended 114 

8.  Ordinary  curved  bistoury  for  opening  abscesses  ....      115 

9.  Author's  design  of  knife  for  opening  abscesses 115 

10.  Author's  design  for  a  probe 118 

11.  Method  of'probing  a  tortuous  sinus 119 


PLATES 


PLATE 


I.     Rapid  immobilization  of  the  broken  bones  of  the  leg. 
Upper  figure. — Limb  covered  with  protective. 
Lower  figure. — Tin  strips  in  position  on  a  foundation 
layer  of  plaster-of-Paris  bandage. 

II.     Rapid  immobilization  of  the  broken  bones  of  the  leg. 
Upper  figure. — Tin   strips    bandaged   to   lower    frag- 
ment. 
Lower  figure. — Finished  splint. 
ix 


LIST   OF   ILLUSTRATIONS 


PLATE 
III. 


IV. 


VI. 


VII. 


VIII. 


IX. 


XI. 

XII. 
XIII. 


Pott's  fracture  near  the  ankle-joint. 
Upper  figure. — Tin  strips  in  position  upon  a  founda- 
tion layer  of  plaster-of-Paris  bandage. 
Lower  figure. — Tin  strips  being  bandaged  in  position. 

Fracture  of  the  shaft  of  the  humerus. 
Left  hand  figure. — Tin  strips  in  position  upon  a  foun- 
dation layer  of  plaster-of-Paris  bandage. 
Right  hand  figure. — Finished  splint. 

Setting  of  a  fracture  of  the  shaft  of  the  femur  with 
tin  strips  and  plaster-of-Paris  bandages.  The 
patient  has  been  moved  to  the  operating-table. 

Upper  figure. — Tin  strips  bandaged  to  lower  fragment. 

Lower  figure. — Reversal  of  tin  strips  at  the  upper 
margin  of  the  splint. 

Suspension  apparatus  applied  to  a  compound  fracture 

of  the  leg  treated  in  a  plaster-of-Paris  splint. 
Patient  lying  upon  his  back. 

Suspension  apparatus  applied  to  a  compound  fracture 

of  the  leg  treated  in  a  plaster-of-Paris  splint. 
Patient  lying  upon  his  face. 

Suspension  apparatus  applied  to  a  compound  fracture 

of  the  leg  treated  in  a  plaster-of-Paris  splint. 
Patient  sitting  up  in  bed. 

Suspension  apparatus  applied  to  a  compound  fracture 

of  the  leg  treated  in  a  plaster-of-Paris  splint. 
Patient  sitting  in  a  chair  beside  his  bed. 

Suspension  apparatus  applied  to  simple   fractures  of 
both  femora  treated  in  a  plaster-of-Paris  splint. 
Patient  turned  upon  his  side. 

Suspension  apparatus  applied  to  simple  fractures  of 
both  femora  treated  in  a  plaster-of-Paris  splint. 
Patient  exercising  upon  the  apparatus. 

Recent  primary  amputation  at  the  thigh  treated  with- 
out dressings,  upon  a  supporting  frame. 

Recent  primary  amputation  at  the  thigh,  the  same  as 
in  plate  xii,  showing  change  of  frame  support — 
no  dressings  upon  the  wound. 


LIST   OF   ILLUSTRATIONS 


XI 


PLATE 

XIV,     Recent  primary  amputation  of  the  forearm  treated  by 
suspension,  without  dressings  upon  the  wound. 
Upper  figure. — Clean   frame  beneath  soiled   frame. 
Middle  figure. — Release    of    the    wire    of    the    soiled 

frame. 
Lower  figure. — Limb  resting  upon  the  clean  frame. 

XV.  Amputation  at  the  ankle-joint  (Syme's)  and  at  the 
middle  of  the  leg  (Stephen  Smith's),  treated  by 
suspension  upon  sectional  supports,  and  without 
dressings  upon  the  wounds. 

XVI.  Upper  figure. — Compound  fracture  of  the  leg  treated 
in  a  fracture-box. 
Lower  figure. — Same  compound  fracture  of  the  leg  as 
in  upper  figure,  treated  in  suspension  apparatus 
with  sectional  supports  and  no  dressings  upon  the 
wounds. 

XVII.  Upper  figure. — Compound  fracture  of  the  leg  treated 
upon  suspension  apparatus  with  sectional  sup- 
ports. Two  supports  and  a  part  of  a  third  have 
been  removed  and  an  abscess  incised.  No  dress- 
ings upon  the  woimds. 
Lower  figure. — Excision  of  the  knee-joint  treated 
upon  suspension  apparatus  with  sectional  sup- 
ports. 

XVIII.     Oblique  fracture  of  the  lower  third  of  the  shaft  of  the 
femur,  with  perfect  union.      Old   osteophyte. 

XIX.     Hand-power  mechanism  of  crochet-drill. 

XX.     A.  Upper    figure. — Pistol-shot    wound    of    the    brain. 
Probe   in  the  wound. 
Lower  figure. — Course  of  the  ball. 

B.  Upper  figure. — Pistol-shot    wound    of    the    brain. 

Course  of  the  ball. 
Lower  figure. — Course  of  the  ball. 

C.  Upper  figure. — Pistol-shot  wound  of  the  brain  be- 

hind the  right  ear. 
Lower  figure. — Course  of  the  ball. 

D.  Upper  figure. — Pistol-shot  wound  of  the  brain. 
Lower  figure. — Course  of  the  ball. 

E.  Upper  figure. — Median  section  of  the  head,  show- 

ing the  falx  cerebri  in  position. 
Lower  figure. — The  inner  face  of  the  cerebral  hemi- 
sphere after  the  removal  of  the  falx  cerebri. 


PRINCIPLES  OF  TREATMENT 
OF  BROKEN  LIMBS 

While  it  is  conceivable  that  in  the  long  processes  of 
time  there  may  be  evolved  such  perfect  adjustment 
of  man  to  the  mechanical  forces  to  which  he  is  ex- 
posed as  to  exclude  the  occurrence  of  fractures  of  the 
bones,  nevertheless  it  may  be  safely  assumed  that  this 
will  never  take  place  in  measurable  time. 

"No  serum  or  other  agent  will  ever  confer  im- 
munity against  these  injuries,  nor  will  measures 
directed  to  their  prevention  through  the  combating 
of  their  causation  ever  be  completely  successful. 
Their  treatment,  therefore,  concerns  one  of  the  few 
enduring  fields  of  surgical  practice. 

It  may  be  supposed  that  such  striking  injuries  as 
broken  bones  must  have  been  the  subject  of  thought- 
ful treatment  from  ancient  times,  and  it  is  very  prob- 
able that  the  procedures  of  long-continued  and  highly 
developed  empiricism  will  often  have  closely  ap- 
proached or  may  sometimes  have  coincided  with  those 
demanded  by  compliance  with  exact  theory. 

In  this  essay  the  attempt  is  made  to  lift  this  lasting 
field  of  surgical  practice  from  empiricism  to  scientific 
exactitude.  The  essay  is  mainly  concerned  in  an  in- 
quiry into  the  principles  of  treatment  of  fractures  of 
some  of  the  long  bones,  with  the  object  of  determining 
the  criterion  of  value  of  the  results  of  treatment.    In 


2         PRINCIPLES   OF   TREATMENT   OF   BROKEN    LIMBS 

this  effort  we  are  carefully  to  discriminate  observation 
of  the  facts  and  their  classification  in  defined  catego- 
ries, from  the  determination  of  their  relative  value  in 
an  ideal  scheme  of  values.  Values  attach  to  results, 
and  results  may  be  even  hypothetical  without  disturb- 
ance of  their  comparison.  Indeed,  the  surgeon  is 
always  engaged  in  efforts  to  realize  in  the  concrete 
ideal  values  of  greater  worth  that  have  appealed  to 
him  in  the  abstract. 

The  determination  of  relative  values  is  not  to  be 
confused  with  skill  required  in  their  practical  realiza- 
tion. Skill  is  concerned  merely  in  the  practical  be- 
neficence of  their  realization  and  distribution. 

Among  the  other  advantages  of  a  clear  perception 
of  the  method  of  determining  relative  values  of  dif- 
ferent methods  of  treatment  founded  upon  scientific 
theory  is  the  important  one  of  conserving  effort  along 
a  line  of  progress,  with  a  consequent  resulting  ten- 
dency to  uniformity  of  practice. 

In  this  essay  free  use  will  be  made  of  established 
common  logical  expressions,  partly  for  cogency,  and 
partly  also  to  enable  critics  the  more  readily  to  expose 
errors  into  which  the  author  may  have  fallen.  In  the 
use  of  ambiguous  terms  important  to  argument,  the 
particular  connotation  of  the  term  in  the  sense  in 
which  it  is  used,  is  sometimes  substituted  for  the  term 
itself. 

The  various  procedures  of  treatment  peculiar  to 
the  author's  practice,  some  of  which  are  avowedly  ob- 
solete, are  nevertheless  described  for  the  purpose  of 
illustration.  In  their  presentation  the  author  par- 
ticularly considers  himself  relieved  of  any  charge  of 


PRINCIPLES   OF  TREATMENT   OF   BROKEN   LIMBS         3 

''begging  the  question"  (petitio  principii).  The 
various  changes  from  usual  methods  of  treatment 
in  vogue  at  the  time,  were  made  to  meet  needs  for 
the  betterment  of  the  patient  which  were  pressed 
upon  his  attention  in  each  individual  instance  by 
bedside  experience,  and  were  not  designed  for  the 
purpose  of  carrying  out  any  preconceived  theory  of 
treatment.  If  any  of  the  author's  methods  are 
adjudged  of  superior  value,  it  is,  so  far  as  the  argu- 
ment is  concerned,  purely  incidental. 

While  the  author  was  a  member  of  the  House 
StaflP  of  Bellevue  Hospital  in  1872,  he  was  struck 
with  the  difficulty  in  many  (fractures  of  the  long 
bones  of  continuously  holding  the  fragments  in  a 
given  desired  adjustment  pending  their  fixation  in 
permanent  retention  apparel.  To  overcome  this 
difficulty  he  devised  a  method  of  more  speedy  fixa- 
tion of  the  fragments  in  adjusted  relation,  by  means 
of  the  use  of  roughened  narrow  tin  strips. 

In  illustration  of  the  practicability  of  the  method 
he  collected  into  his  service  a  large  number  of  vari- 
ous recent  fractures,  in  which  the  Hospital  abounded 
and  invited  members  of  the  Visiting  Staff  and  other 
surgeons  present  at  the  demonstration,  to  select  ex- 
amples as  tests  of  the  method.  There  were  chosen, 
a  simple  fracture  of  the  shaft  of  the  femur,  a  Pott's 
fracture  with  great  displacement  of  the  foot,  and  a 
fracture  of  both  bones  at  the  middle  of  the  leg  with 
great  mobility  at  the  seat  of  fracture.  To  the  satis- 
faction of  all  present,  these  fractures  were  treated 
in  turn  by  the  method,  using  plaster-of-Paris  band- 


4         PEINCIPLES    OF   TREATMENT   OF   BROKEN    LIMBS 

ages  for  the  construction  of  the  permanent  retentive 
apparel. 

The  p'atient,  with  fracture  of  both  bones  of  the 
leg,  before  treatment  suffered  much  pain  upon  the 
slightest  disturbance  of  his  broken  leg.  As  soon  as 
the  tin  strips  had  been  fastened  in  position,  no  an£es- 
thetic  having  been  given,  although  the  plaster-of- 
Paris  bandages  were  still  wet,  and  the.  plaster  had 
not  begun  to  harden,  to  the  surprise  of  the  audience, 
the  patient  delightedly  waved  his  broken  leg  about 
without  pain,  till  he  was  told  to  desist. 

Photographs  of  illustrative  instances,  together  with 
a  very  brief  description  of  the  mechanical  principles 
involved  in  the  method,  were  a  part  of  the  exhibit  of 
Bellevue  Hospital  sent  by  the  Commissioners  of 
Public  Charities  and  Correction  to  the  World's  Fair 
of  1873.  The  author  having  abundant  opportunity 
while  in  charge  of  the  Reception  Hospitals,  which 
cared  for  a  very  large  emergency  service,  as  well  as 
in  other  hospital  services  embracing  a  great  number 
of  fractures,  amply  confirmed  the  utility  of  the 
method.  In  those  days,  by  invitation  of  Prof.  Frank 
H.  Hamilton,  and  Prof.  Lewis  A.  Sayre,  practical 
demonstrations  of  the  method  were  given  before  their 
college  classes,  as  well  as  on  other  occasions. 

If  it  be  conceived  that  in  a  given  longitudinal 
plane  of  the  leg  a  rigid  truss  extending  between  the 
fragments  is  fastened  to  the  bones,  obviously  the 
fragments  would  be  held  immovable  in  that  plane. 
As  by  reference  to  the  diagram  Fig.  1  we  perceive, 
having  to  deal  with  soft  living  structures,  it  is  pos- 
sible to  make  rigid  only  the  surface,  or  exposed  mem- 


PRINCIPLES    OF   TREATMENT    OF    BROKEN    LIMBS         5 

ber  of  the  truss;  other  members  of  the  truss  are 
constituted  by  the  soft  tissues  themselves.  The  same 
is  true  of  all  splints  as  extrinsic  apparel  acting  in 
resistance  to  forces  tending  to  displace  the  adjusted 
fragments.  However,  there  is  a  limit  to  the  safe 
compression  of  the  soft  tissues  by  the  constricting 
bandage  and  their  consequent  approach  to  rigidity, 
therefore  it  is  not  practicable  to  hold  the  fragments 


Fig.  1. — A  Diagrammatic  Representation  of  a  Truss  in  the 
Median  Longitudinal  Plane  of  the  Leg  in  a  Fracture  of 
the  Tibia.  Deep  members  of  the  truss  are  indicated  by 
dotted  lines;  the  superficial  member  of  the  truss  is  the  tin 
strip. 

of  bone  absolutely  immobile  in  the  presence  of  dis- 
turbing forces  by  means  of  any  extrinsic  apparel 
exerting  its  resistance  through  the  soft  parts. 

An  immovable  plaster-of-Paris  splint,  encasing  the 
limb,  is  efficient  in  resistance  to  displacement  of  the 
adjusted  bony  fragments  in  a  degree  proportional 
to  its  compression  of  the  soft  parts.  Even  the  best 
applied,  tightest  fitting  splint  is  incapable  of  holding 
the  fragments  absolutely  immovable  when  they  are 
exposed  to  active  disturbing  forces.     In  an  instance 


6         PRINCIPLES    OF    TREATMENT    OF    BROKEN    LIMBS 

of  a  compound  fracture  of  both  bones  of  the  leg,  the 
author  found  immediately  after  applying  a  tight 
fitting  plaster-of-Paris  splint  that  upon  introducing 
the  finger  through  the  wound  down  to  the  fragments, 
they  moved  upon  each  other  when  the  patient  gave 
the  slightest  cough,  the  leg  lying  upon  the  bed. 

By  reference  to  the  diagram,  to  repeat,  it  will  be 
noted  that  the  only  member  of  the  truss  that  can 
be  made  rigid  is  the  one  located  at  the  surface  of 
the  limb,  the  other  members  being  constituted  by  the 
compressed  living  soft  tissues.  In  the  case  of  the 
plaster-of-Paris  splint  as  usually  applied,  the  pros- 
pective member  of  the  truss  located  at  the  surface 
of  the  limb,  at  first  soft  and  yielding,  becomes  rigid 
and  effective  by  the  hardening  of  the  plaster-of- 
Paris,  which  requires  a  certain  interval  of  time,  dur- 
ing which  the  desired  adjusted  relation  of  fragments 
must  be  maintained;  the  longer  the  interval  of  time, 
the  greater  the  probability  of  the  disturbance  of  the 
desired  relation. 

In  the  author's  invention  the  rigid  superficial  mem- 
bers of  the  truss,  perfectly  adapting  themselves  to 
the  contour  of  the  limb  and  developing  rigidity  when 
bandaged  to  the  limb,  were  made  of  narrow  tin  strips 
and  became  immediately  effective  as  a  resistance  to 
disturbing  forces  as  soon  as  fastened  by  bandages 
to  the  surface  of  the  limb,  thus  securing  the  advan- 
tage of  limiting  the  required  maintenance  of  the 
adjustment  of  the  fragments  in  desired  relation  to 
a  minimum  length  of  time,  thereby  practically  ex- 
cluding the  chances  of  a  disturbance  of  that  elected 
adjustment. 


rPRINCIPLES   OF  TREATMENT   OF   BROKEN   LIMBS         7 

The  tin  strips  are  effective  on  account  of  the  ab- 
sence of  extensibility  and  contractibility,  neither 
lengthening  nor  shortening  when  in  action  as  a  re- 
sistance between  the  retaining  layers  of  bandage. 
In  addition  to  the  important  advantage  of  immobiliz- 
ing the  fragments  of  bone  in  the  briefest  interval 
of  time,  and  under  the  most  favorable  conditions  for 
their  correct  adjustment,  they  present  the  further 
advantage  of  scope  of  efficiency  in  affording  an  ex- 
tended range  of  choice  of  the  material  that  may  be 
used  for  the  construction  of  the  permanent  splint 
or  apparel ;  the  strips  are  even  effective  when  secured 
between  layers  of  dry  bandage,  but  still  more  effi- 
cient when  used  between  layers  of  wet  bandage. 

While  the  author's  experience  in  the  use  of  the  tin 
strips  as  a  means  of  rapidly  immobilizing  the  bony 
fragments  has  been  limited  to  civil  practice,  their 
superior  utility  in  the  exigencies  of  military  practice 
must  be  evident.  In  military  practice  the  prompt- 
ness of  setting  the  fracture,  and  consequently  the 
quick  preparation  of  the  patient  for  safe  trans- 
port are  paramount  considerations  and  often,  no 
doubt,  determine  the  question  of  preservation  or 
sacrifice  of  the  injured  limb. 

The  time  element  in  the  treatment  of  fractures 
is  so  important  that  for  "first  aid,"  soldiers  should 
be  provided  with  two  or  three  flannel  bandages  about 
three  inches  wide  and  eight  yards  long,  two  or  three 
muslin  bandages  of  the  same  dimensions  and  three 
or  four  antiseptic  bandages  of  the  construction  orig- 
inally devised  by  Lister.  These  last,  apart  from 
their  antiseptic  value,  have  a  special  advantage  in 


8         PRINCIPLES   OF   TREATMENT   OF   BROKEN    LIMBS 

securing  the  tin  strips  in  position.  Being  gummy, 
their  folds  readily  stick  together.  In  addition  to 
the  bandages,  the  soldier  should  be  provided  "vvith 
four  properly  prepared  tin  strips. 

In  possession  of  this  surgical  equipment,  there  is 
the  important  consideration  that  the  broken  hones 
may  he  immohilized  without  the  use  of  plaster-of- 
Paris  or  even  of  water,  both  of  which  may  be  diffi- 
cult to  obtain. 

The  flannel  bandages,  which  at  least  may  be 
sterilized,  are  an  excellent  substitute  for  the  blanket 
protective  covering  of  the  limb  and  can  be  quickly 
applied. 

The  surgical  material  mentioned  is  of  trivial 
weight.  The  splint  being  made  of  the  strips,  when 
fastened  in  position,  fractures,  perhaps  excepting 
those  of  the  thigh,  could  be  unmobilized  immediately 
after  injury,  even  on  the  battle-field.  In  case  of 
fractures  of  the  thigh,  the  benefit  of  some  degree  of 
immobilization  could  be  obtained. 

As  a  part  of  his  military  training  every  soldier 
should  receive  lessons  in  handagiiig,  which  education 
may  in  an  emergency  he  the  means  of  saving  his 
own  or  a  comrade's  life. 

The  tin  strips  are  cut  one-quarter  of  an  inch  wide 
from  ordinary  thin  sheet  tin.  Additional  length, 
if  necessary,  may  be  obtained  by  soldering  two  or 
more  strips  together.  They  are  roughened  that  they 
may  be  securely  held  between  layers  of  bandage,  by 
punching  holes  along  the  centre  line  of  their  length. 
These  holes  are  made  about  one  inch  apart,  alter- 
nately on  either  side,  by  a  round  pointed  awl.    The 


PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS         9 

punching  throws  out  little  jagged  points  of  tin 
around  the  margin  of  each  hole,  which  give  to  the 
bandage  an  effective  hold  upon  the  strip.  Care  is 
taken  not  to  make  the  holes  too  big,  throwing  out 
too  large  projecting  points  of  tin  which  may  inter- 
fere with  the  smooth  application  of  the  retaining 
bandage  and  thus  obscure  the  outline  of  the  limb, 
one  of  the  best  guides  to  the  correct  adjustment  in 
line,  of  the  fragments  of  bone.  After  being  rough- 
ened, the  strips  are  carefully  straightened  for  use. 

The  procedure  of  their  use  in  detail  is  as  follows : 
taking,  for  an  example,  a  fracture  of  both  bones  of 
the  leg  about  the  middle,  with  great  mobility  at 
the  site  of  fracture.  It  is  emphasized  that  the  fixa- 
tion of  the  adjusted  fragments  is  to  be  accomplished 
by  means  of  the  tin  strips,  and  that  the  material  used 
for  the  construction  of  the  permanent  splint  is  for 
the  continuance  of  the  initial  fixation.  The  use  of  the 
tin  strips  is  not  for  the  purpose  of  strengthening  the 
constructed  splint,  which  no  doubt  to  some  extent 
is  a  secondary  effect;  they  are  themselves  the  splint, 
within  the  stated  connotation  of  the  term. 

The  guides  for  the  correct  adjustment  of  the  frag- 
ments at  the  time  of  their  immobilization  are: — ^the 
assurance  of  the  touch,  palpation;  the  proper  outline 
of  the  limb  as  disclosed  by  its  uninjured  fellow;  and 
possibly  tJie  revelations  of  the  fluoroscope  or  X-ray. 
It  is  highly  important  that  the  adjustment  of  the 
fragments  shall  be  accomplished  under  conditions 
wherein  the  guides  are  most  helpful. 

The  limb  is  first  covered  with  protective  material 
to  prevent  immediate  contact  of  the  plaster-of-Paris 


10       PRINCIPLES    OF   TREATMENT    OF   BROKEN    LIMBS 

with  the  skin  and  in  some  slight  degree  to  cushion 
tissues  overlying  superficial  bones  in  places  intolerant 
of  undue  pressure.  In  the  case  of  the  leg  splint  such 
places  are  the  point  of  the  heel,  the  instep  and  the 
tubercle  and  spine  of  the  tibia.  Care  should  be  taken 
not  to  make  the  protective  covering  too  thick  at  these 
designated  places.  No  padding  of  cotton  or  other 
such  material  should  ever  be  used.  It  would  deform 
the  important  outline  of  the  limb  and  interfere  with 
the  efficiency  of  the  splint. 

To  avoid  undue  disturbance  of  the  sensitive  broken 
limb  and  a  chance  increase  of  swelling,  it  is  better  to 
adapt  a  covering  of  thin  old  blanket,  or  similar  ma- 
terial rather  than  to  force  a  stocking  or  other  ready- 
made  covering,  upon  the  limb.  The  covering  should 
be  gently  adjusted  in  position  with  such  neatness  and 
skill  that  it  does  not  obscure  but  preserves  the  dis- 
tinctness of  the  outline  of  the  limb.  The  protective 
which  covers  the  inner  and  anterior  aspects  of  the 
limb  should  overlap  that  portion  which  covers  the 
posterior  and  external  surfaces.  The  overlying  fold 
where  the  covering  joins,  which  is  held  by  pins  with 
their  points  directed  outward,  should  fall  along  the 
outer  aspect  of  the  limb,  away  from  the  most  im- 
portant outline  concerned  in  the  adjustment  of  the 
fragments,  where  the  tibia  is  superficial  and  accessible 
to  the  touch,  and  thus  oppose  no  obstacle  to  the 
scientifically  made  turns  of  the  bandage.  Except 
in  fractures  at  the  very  lowermost  portion  of  the  leg 
it  is  well  to  have  the  splint  include  the  knee-joint  and 
infringe  upon  the  thigh.  One  layer  of  protective 
covering,  except  in  the  places  specified,  is  sufficient. 


PLATE    I. 

Rapid  Immobilization  of  Broken  Bones  of  the  Leg. 

Upper  Figure. — Limb  covered  with  protective. 
Lower   Figure. — Foundation  layer  of   plaster-of-Paris   band- 
age; tin  strips   in  position. 


PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS      11 

In  fractures  of  the  leg,  measurements  are  of  little 
value  in  aiding  the  efforts  for  the  correction  of  the 
shortening,  which  is  usually  inconsiderable  and  easily 
sufficiently  overcome,  even  without  the  use  of  an 
anaesthetic. 

In  bandaging  secundum  artem,  which  should  al- 
ways be  practiced,  the  turns  of  the  bandage  should 
be  made  from  the  median  line  of  the  body  outward 
across  the  anterior  surface  of  the  limb;  in  conse- 
quence, therefore,  the  right  leg  is  bandaged  left 
handedly,  the  left  leg,  right  handedly,  the  operator 
standing  at  the  patient's  side  with  his  face  directed 
toward  that  of  the  patient.  The  roller  bandage  made 
of  thin  unbleached  muslin  should  be  rather  narrow, 
from  two  to  three  inches  wide,  and  six  to  eight  yards 
long.  A  very  little  plaster-of-Paris  is  rubbed  into 
each  side  of  the  bandage,  just  whitening  it,  in  order 
that  the  bandage  may  be  very  easily  wetted  when 
immersed  in  water.  Should  there  be  much  plaster 
upon  the  bandage  it  would  be  apt  to  form  into  lumps 
and  deform  the  outline  of  the  limb. 

It  is  always  to  be  borne  in  mind  that  the  initial 
fixation  of  the  adjusted  fragments  is  to  be  accom- 
plished by  the  action  of  the  tin  strips  independently 
of  the  setting  of  the  plaster-of-Paris,  the  wet  band- 
age serving  the  purpose.  The  bandage  is  rolled 
evenly  but  rather  loosely  so  it  will  moisten  readily 
to  the  core  without  the  plaster  first  setting  on  the 
outer  layers.  No  agent  should  be  added  to  the  tepid 
water  in  which  the  bandages  are  immersed  to  hasten 
the  setting  of  the  plaster,  indeed,  a  too  quick  setting 
of  the  plaster  is  to  be  avoided.    Three  or  four  band- 


12      PRINCIPLES   OF  TREATIVIENT   OF   BROKEN  XIMBS 

ages  are  immersed  in  the  basin  of  tepid  water.  As 
one  is  used  a  diy  one  replaces  it  till  the  requisite 
number  have  been  wetted.  In  using  a  bandage  it 
should  be  freed  from  an  excess  of  water  by  pres- 
sure upon  it  sides,  avoiding  pressure  upon  its  ends. 
All  loose  ravelings  should  be  cleared  away  so  as  not 
to  embarrass  or  delay  the  surgeon  while  at  work. 
All  these  details,  some  of  them  apparently  trivial,  are 
mentioned,  as  a  regard  for  them  contributes  to  the 
making  of  the  perfect  splint. 

An  assistant,  comfortably  seated,  seizes  the  broken 
limb  by  the  foot  and  drags  it  over  the  edge  of  the 
bed,  giving  the  surgeon  plenty  of  operating  space, 
at  the  same  time  making  moderate  extension. 

Commencing  at  the  base  of  the  toes,  which  are 
left  exposed,  the  surgeon  snugly  applies  one  layer 
of  bandage  to  the  previously  covered  limb,  as  far 
as  the  designed  limits  of  the  splint.  For  the  best 
construction  of  the  splint  the  bandage  is  applied  by 
making  figure  of  eight  turns,  the  reverses,  where 
necessary,  being  made  posteriorly,  away  from  the 
more  imjDortant  outline  of  the  limb.  As  the  bandage 
is  applied  it  fastens  down  the  overlapping  fold  of  the 
protective  covering,  permitting  the  removal  of  the 
retaining  pins. 

Practical  skill  in  bandaging  is  a  positive  pre- 
requisite to  tJie  construction  of  an  immovable  plaster- 
of-Paiis  splint.  In  preantiseptic  days,  when  Bellevue 
Hospital  was  saturated  with  infection,  the  ever-im- 
minent probability  of  the  infection  of  a  wound,  es- 
pecially a  recent  one,  was  a  great  discouragement 
to  cutting  operations.    As  a  consequence,  attention 


PRINCIPLES    or   TKEATMENT    OF    BROKEN    LIMBS      13 

was  concentrated  upon  bloodless  operations.  In 
these,  as  well  as  in  the  septic  surgery,  as  then  prac- 
ticed, bandaging  ^^laved  a  very  important  part.  The 
members  of  the  House  Staff  of  those  days  became 
proficient  in  bandaging.  A  novice  may  be  taught 
how  to  make  the  necessary  turns  in  bandaging,  but 
the  degree  of  compression  of  the  tissues  to  be  exerted 
by  means  of  the  bandage  can  never  be  adequately 
taught.  It  must  be  acquired  by  experience.  It  be- 
longs to  the  'Hactus  eriiditus"  an  acquirement  upon 
which  the  older  surgeons  very  properly  laid  great 
emphasis.  To  know  just  what  amount  of  compres- 
sion injured  tissues  can  safely  bear,  an  element  of 
their  surgical  functioning,  is  a  matter  of  judgment 
gained  only  by  experience.  When  it  is  considered 
that  the  greatest  efficiency  of  the  immovable  apparel 
is  developed  through  the  greatest  amount  of  com- 
pression that  the  soft  tissues  can  safely  tolerate,  the 
careful  training  of  the  judgment  and  the  skill  neces- 
sary to  insure  that  greatest  efficiency  may  be  ap- 
preciated. 

The  first  layer  of  bandage  when  applied  is  little 
more  than  a  covering  of  wet  bandage.  The  splint 
during  its  construction  should  be  kept  rather  wet, 
short  of  dripping.  This  layer  of  snugly  and  evenly 
applied  bandage  preserves  the  outline  of  the  limb 
sharp  and  distinct.  A  little  dry  plaster  is  held  in 
the  hand  under  water  till  thoroughly  moistened  and 
then  rubbed  into  the  layer  of  bandage,  smoothly 
sticking  the  folds  together  and  making  the  proper 
basis  for  the  strips  to  rest  upon.  If  this  basis  should 
be  judged  to  be  not  firm  enough  as  a  foimdation  for 


14       PRINCIPLES    OF   TREATMENT    OF    BROKEN    LIMBS 

the  strips,  which  is  usually  the  fact,  a  second  layer 
of  bandage  is  applied. 

A  few  imaginary  principal  longitudinal  planes  of 
the  limb  are  located,  in  which,  after  correcting  exist- 
ing deformity,  immobility  is  to  be  secured. 

At  least  four  or  five  tin  strips,  as  in  the  illus- 
tration, are  used  in  said  planes.  The  strips  at  first 
are  to  extend  beyond  the  limits  of  the  finished  splint, 
from  the  toes  to  a  line  upon  the  thigh.  One  strip  is 
placed  on  either  side  of  the  anterior  median  line  and 
one  in  the  posterior  median  line,  respectively;  the 
latter  strip  starts  from  beyond  the  toes  and  extends 
along  the  middle  of  the  sole  of  the  foot  upward  along 
the  limb  in  the  posterior  median  line ;  the  former  ex- 
tends correspondingly  along  either  side  of  the  an- 
terior median  line  of  the  limb.  Two  principal  side 
strips  are  used,  one  on  either  side  in  the  principal 
horizontal  plane  of  the  limb.  They  start  upon  the 
sole  of  the  foot  from  beyond  the  toes  and  extend  on 
either  side  of  the  posterior  median  strip  to  a  point 
upon  the  heel  where  they  are  directed  by  a  reverse 
nearly  at  a  right  angle  into  a  general  course  up  the 
limb,  on  either  side  respectively,  in  its  principal  hori- 
zontal plane. 

The  strips  which  may  be  prepared  beforehand  are 
secured  to  the  foot  by  two  or  three  turns  of  bandage 
and  any  errors  in  their  general  course  along  the  limb 
are  corrected  at  the  early  start.  The  figure  of  eight 
turns  of  bandage  are  continued,  firmly  securing  the 
strips  in  relation  to  the  lower  fragment,  as  far  as  the 
place  of  fracture  (see  Plate  II) .  During  this  bandag- 
ing the  exposed  portions  of  strips  are  uncontrolled 


PLATE    II. 

Rapid  Immobilization  of  the   Broken  Bones  of  the  Leg. 

Upper  Figure. — Tin  strips  bandaged  in  relation  to  the  lower 
fragment  as  far  as  site  of  fracture. 

Lower  Figure. — Finished  splint.  Strips  bandaged  in  position 
without  deforming  the  outline  of  the  limb. 


PRINCIPLES    or   TREATMENT   OF   BROKEN    LIMBS      15 

and  allowed  to  hang  free,  and  thus  adapt  themselves 
to  the  contour  of  the  limb  as  the  bandaging  pro- 
gresses. The  strips  having  been  firmly  secured  to 
the  lower  fragment  as  far  as  the  point  of  false  motion 
at  the  site  of  fracture,  the  surgeon  then  carefully 
directs  his  efforts  to  correcting  the  existing  deformity. 
The  guides  to  effect  the  attainment  of  this  object 
have  not  been  obscured  and  the  conditions  for  mak- 
ing a  correct  adjustment  are  of  the  best;  the  out- 
line of  the  limb  has  been  preserved  sharp  and  dis- 
tinct; there  is  no  obstacle  to  the  exercise  of  the 
touch  or  the  use  of  measurements. 

Under  the  direction  of  the  surgeon  the  assistant 
now  exerts  the  full  force  of  extension.  The  surgeon 
then  makes  the  necessary  corrective  manipulation  to 
overcome  any  angular  or  other  deformity  and  while 
these  procedures  are  continued  in  full  play,  he  rapidly 
extends  the  turns  of  bandage  upward  fastening  the 
exposed  free  portions  of  the  strips  home  to  their 
base  and  in  relation  to  the  upper  fragment.  As  soon 
as  this  is  done,  which  takes  only  a  brief  fraction  of 
time,  a  few  seconds,  the  fragments  are  firmly  held 
in  their  given  adjusted  relation.  Moistened  plaster 
is  rubbed  into  the  layer  of  bandage  as  was  the  case 
with  the  first  layer. 

The  ends  of  the  tin  strips  extending  beyond  the 
margins  of  the  splint  are  trimmed  to  a  length  of  two 
or  three  inches,  turned  back  upon  the  splint  together 
with  a  finishing  turned  over  cuff  of  the  protective 
covering,  and  secured  by  plaster-of-Paris  bandage. 

While  the  splint  should  be  strengthened  by  lengths 
of  plaster-of-Paris  bandage,  or  pieces  of  old  blanket 


16       PRINCIPLES    OF   TREATMENT   OF   BROKEN    LIMBS 

saturated  with  a  thin  cream  of  plaster-of-Paris, 
bandaged  into  position,  in  places  especially  exposed 
to  injury  during  the  wear  of  a  month's  or  six  weeks' 
duration,  it  should  not  be  made  so  thick  over  the 
portions  of  bones  lying  superficially  and  exposed  to 
pressure,  but  that  if  required,  undue  pressure  may 
be  eased  in  such  places  by  pressing  the  hardened 
splint  between  the  hands. 

The  splint  is  finished  (see  Plate  II)  by  rubbing 
into  its  surface  moistened  plaster  and  smoothing  the 
same  with  rather  wet  hands.  This  finishing  process 
should  not  be  continued  too  long,  otherwise  it  will 
disturb  the  initial  set  of  the  plaster  and  cause  it  to 
"flour." 

When  the  splint  is  finished  the  patient  is  replaced 
upon  his  bed  till  the  splint  hardens. 

The  exposed  toes  are  carefully  watched  as  the 
tell-tale  of  the  condition  of  the  circulation.  Being 
assured  that  the  circulation  of  the  limb  is  in  safe 
condition,  the  surgeon  should  induce  the  patient  to 
leave  his  bed  and  walk  with  crutches  as  soon  as 
possible. 

In  the  treatment  of  compound  fractures  of  the 
leg  strict  antiseptic  measures  should,  of  course,  be 
practiced.  All  compound  fractures  due  to  injury 
should  be  regarded  as  infected  and  the  surgeon  should 
never  hesitate  for  a  moment  to  enlarge  the  wound 
communicating  with  the  fracture  to  insure  its  com- 
plete disinfection.  Ample  drainage  of  the  wound 
should  be  provided  for  under  such  circumstances. 
In  place  of  the  protective  covering  of  thin  blanket 
an  antiseptic  covering  material  should  be  specially 


PLATE    III. 


Pott's  Fracture  near  Ankle-Joint. 


Upper    Figure. — Tin    strips    in    position    upon    a    foundation 
layer  of  plaster-of-Paris  bandage. 

Lower  Figure. — Tin  strips  being  bandaged  in  position. 


PRINCIPLES    OF   TREATMENT   OF   BROKEN    LIMBS      17 

prepared.  This  may  be  made  of  a  layer,  not  too 
thick,  of  'antiseptic  cotton,  held  between  layers  of  an- 
tiseptic gauze  (bichloride)  and  quilted.  The  tin  strips 
are,  of  course,  sterilized  by  immersion  in  an  antiseptic 
solution  or  by  heat.  The  original  Lister  antiseptic 
bandages,  somewhat  gummy  from  the  resinous  com- 
bination used  in  their  construction,  are  highly  useful. 
Bichloride  bandages  will,  however,  answer  the  pur- 
pose. The  tin  strips  are  bandaged  in  position  in  the 
same  manner  as  if  plaster-of-Paris  bandages  were 
used.  After  the  fragments  have  been  immobilized, 
layers  of  antiseptic  gauze  are  bandaged  about  the 
region  of  the  wound  in  sufficient  quantity  to  absorb 
the  secretions  regardless  then  of  deforming  the  out- 
line of  the  limb.  If  desired,  a  more  permanent 
character  may  be  given  to  the  retentive  apparel  by 
applying  plaster-of-Paris  bandages  over  all. 

The  author  emphasizes  the  importance  of  using 
antiseptic  instead  of  sterile  dressings  to  absorb  the 
wound  secretions.  Sterile  dressings  saturated  with 
such  secretions  and  held  in  contact  with  warm  tissues 
furnish  ideal  conditions  for  germ  growth.  The  use 
of  sterile  dressings  in  septic  surroundings  instead  of 
antiseptic  dressings  to  absorb  wound  secretion  is  in 
the  author's  judgment  an  unjustifiable  procedure. 

In  a  Pott's  fracture  with  displacement  of  the  foot, 
one  of  the  tin  strips  is  so  placed  as  to  correct  the 
deformity,  secure  inversion  of  the  foot  and  prevent 
motion  in  the  plane  of  displacement.  Said  tin  strip 
starting  upon  the  sole  of  the  foot  is  reversed  at  the 
heel  so  as  to  take  a  course   diagonally  across   the 


18       PRINCIPLES    OF   TREATMENT    OF    BROKEN    LIMBS 

anterior  aspect  of  the  ankle  in  a  direction  from  within 
outward,  as  shown  in  Plate  III. 

In  a  fracture  of  the  humerus  the  tin  strips  may 
be  applied  as  shown  in  Plate  IV,  if  the  use  of  an 
immovable  splint  is  thought  to  be  desirable,  which, 
however,  has  only  exceptionally  been  the  author's 
practice.  It  is  to  be  noted  that  the  immovable 
plaster-of-Paris  splint,  except  in  skilled  hands,  is  a 
highly  dangerous  apparel  for  fractures  in  the  upper 
extremity,  where  the  delicate  soft  tissues  are  ex- 
tremely intolerant  of  pressure.  The  author  has  been 
called  upon  to  amputate  limbs  in  a  number  of  in- 
stances of  traumatic  gangrene  caused  by  too  tight 
bandaging,  but  most  frequently  in  cases  of  faulty 
bandaging  of  the  arm  and  forearm.  Curiously,  none 
of  these  mishaps  has  been  encountered  in  instances 
of  application  of  the  plaster-of-Paris  splint. 

In  the  treatment  of  fractures  of  the  shaft  of  the 
femur  more  forcible  extension  to  overcome  the  short- 
ening of  the  limb  must  be  employed  than  in  the 
case  of  fractures  of  the  leg,  in  which  manual  exten- 
sion, with  or  without  anaesthesia,  suffices  to  over- 
come the  moderate  amount  of  shortening. 

It  will  be  instructive  to  briefly  trace  the  evolution 
of  the  special  apparatus  for  the  setting  of  fractures 
of  the  femur  in  the  plaster-of-Paris  splint  in  use  in 
Bellevue  Hospital  during  the  seventies,  when  under 
the  great  emulation  in  the  practice  of  treating  frac- 
tures in  such  splints  the  art  was  brought  to  the  high- 
est pitch  of  perfection  by  the  House  Staff  of  the 
hospital. 

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PLATE    V. 

Setting  Fracture  of  the  Shaft  of  the  Femur  with  Tin  Strips  and 

Plaster-of-Paris    Bandages.      The   patient   has   been   moved 

from  his  bed  to  the  operating-table. 

Upper  Figure. — Tin  strips  bandaged  to  foundation  layer  of 
plaster-of-Paris  bandage  as  far  as  the  site  of  fracture. 

Lower  Figure. — Strips  reversed  downward  from  upper  mar- 
gin of  the  splint. 


PRINCIPLES   OF  TREATMENT  OF  BROKEN   LIMBS      19 

straight  upright  perineal  bar  clamped  to  the  edge  of 
a  table.  ( See  Plate  V. )  The  patient  was  anaesthetized 
in  his  bed,  then  transported  to  the  table,  and  while 
prone  was  placed  astride  the  bar.  His  pelvis  was 
suspended  by  a  folded  sheet  looped  from  a  narrow 
strip  of  wood,  one  end  of  which  rested  upon  the  end 
of  the  perineal  bar  and  the  other  upon  a  stool  or 
other  support  placed  upon  the  table,  beyond  the 
patient's  head.  The  wood  was  always  in  the  way  of 
the  angesthetizer  and  frequently  slipped  from  posi- 
tion. One  of  the  House  surgeons  substituted  a  band- 
age for  the  sheet  to  suspend  the  patient's  pelvis. 
The  bandage  at  the  middle  of  its  length  was  tied  to 
the  perineal  bar  at  about  the  place  the  perineum 
would  bear;  about  six  inches  from  the  bar  it  was 
knotted  together,  the  ends  to  be  brought  along  each 
side  of  the  pelvis  and  attached  to  the  overhead  strip 
of  board.  This  bandage,  suspending  the  pelvis,  was 
built  into  the  splint  during  its  construction  and  was 
sometimes  withdrawn  when  the  splint  was  completed, 
otherwise  it  was  simply  cut  close  to  the  splint,  when 
releasing  the  patient  from  the  bar.  The  first  im- 
provement made  by  the  author  dispensed  with  the 
troublesome  overhead  strip  of  board  altogether,  by 
bending  the  upper  portion  of  the  perineal-bar  at  a 
right  angle  and  extending  it  about  five  inches  hori- 
zontally over  the  pelvis  with  a  short  lip  or  projection 
on  its  upper  surface,  thus  making  the  point  of  sus- 
pension integral  with  the  bar  itself. 

Under  the  great  tractive  force  exerted  by  means 
of  the  compound  pulleys,  the  bracing  of  the  table 
would  yield,  or  the  edge  of  the  table  would  some- 


20       PRINCIPLES    OF   TREATMENT   OF   BROKEN    LIMBS 

times  break.  Furthermore,  there  was  still  the  neces- 
sity of  transporting  the  patient  back  and  forth  from 
his  bed  to  the  operating  table  with  the  chance  of  a 
considerable  disturbance  of  the  broken  limb  while  in 
transit.  In  one  patient  under  the  author's  observa- 
tion, but  not  in  his  practice,  the  bending  of  the  limb 
during  the  struggles  of  the  patient  caused  the  frag- 
ments to  lacerate  the  femoral  vein,  resulting  in  his 
death.  The  imperfect  means  of  counter-extension, 
the  necessity  of  transporting  the  patient,  and  the  pos- 
sible accidents  incident  thereto,  led  the  author  to  de- 
vise the  construction  which  he  used  ever  after  with 
the  greatest  satisfaction  and  without  the  occurrence 
of  the  slightest  accident. 

The  apparatus  could  easily  be  made  more  portable 
for  use  in  military  practice. 

The  contrivance,  inexpensive  and  easy  of  construc- 
tion, consists  of  a  perineal-bar  fixedly  mounted  in  a 
wooden  tripod  as  shown  in  the  frontispiece.  The 
perineal-bar  is  made  of  a  length  of  half-inch  of  five- 
eighths  of  an  inch  bore  gas-pipe  projecting  above 
the  centre  wooden  block  or  body  of  the  tripod  into 
which  it  is  securely  fastened.  Into  the  free  upper 
end  of  this  pipe  is  received  for  five  or  six  inches  a 
smaller  pipe  which  extends  about  six  inches  above 
the  larger  pipe  or  perineal-bar  and  which  is  then  bent 
to  extend  horizontally  about  six  inches,  terminating 
in  an  upturned  lip.  This  piece  is  removable  and 
taken  out  when  the  patient  is  being  placed  astride  the 
perineal-bar.  When  fitted  into  the  larger  section  of 
pipe  it  holds  its  position  by  friction,  the  portion  slid- 
ing into  the  perineal  upright  is  slightly  bent  out  of 


'PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS      21 

its  long  axis  so  th'at  it  will  hold  by  friction  when 
fitted  into  place.  The  perineal-bar  is  cushioned 
where  the  perineum  will  bear,  by  being  wound  with  a 
strip  of  blanket  or  other  material  held  in  place  by  dry 
bandage.  It  is  advisable,  for  reasons  that  will  be 
given  later,  not  to  cushion  the  perineal  upright  to  a 
great  thickness  with  the  idea  of  saving  the  urethra 
from  pressure. 

In  older  practice  with  the  original  perineal-bar, 
operators  sometimes  padded  the  bar  to  a  great  thick- 
ness, often  to  two  inches  or  more  in  diameter.  This 
of  necessity  brought  pressure  upon  the  middle  line 
of  the  perineum.  But  even  with  this  faulty  practice 
no  harm  ever  came  to  the  urethra.  The  bar  of 
smaller  diameter,  however,  may  be  crowded  against 
the  injured  thigh  past  the  middle  line,  thus  saving 
the  urethra  from  pressure.  A  sufficient  length  of 
medium-sized  copper  wire  is  fastened  at  its  middle 
to  the  perineal-bar  at  about  the  place  the  patient's 
perineum  will  have  a  bearing  when  he  is  in  position ; 
the  strands  of  this  wire  are  twisted  together  for  about 
six  inches  and  then  allowed  to  hang  free.  Its  us6 
will  be  stated  subsequently. 

No  bloodless  operation  comes  to  the  writer's  mind 
that  requires  more  skill  in  its  successful  performance 
than  the  setting  of  a  fracture  of  the  shaft  of  the 
femur  in  an  immovable  splint.  Errors  of  skill  in  the 
application  of  a  movable  splint  may  be  corrected  dur- 
ing the  early  stages  of  treatment,  thereby  averting 
the  evil  consequences  of  mistakes.  In  applying  an 
immovable  splint,  however,  all  the  skill  necessary  to 
eliminate  the  consequences  of  mis-steps  must  be  con- 


22       PEINCIPLES   OF  TREATMENT   OF   BROKEN   LIMBS 

centrated  in  less  than  an  hour's  work.  As  an  illus- 
trative instance  we  will  take  for  treatment  a  supposed 
patient  with  a  recent  simple  oblique  fracture  of  the 
shaft  of  the  femur  at  the  middle  of  its  length  with 
marked  shortening  of  the  limb. 

The  immovable  apparel  should  be  applied  as  soon 
after  the  patient  has  reacted  from  the  shock  of  the 
injury  as  the  condition  of  the  limb  in  reference  to 
swelling,  will  allow.  The  nearer  the  application  of 
the  splint  to  the  time  of  the  receipt  of  the  injury,  the 
more  easily  can  a  correct  adjustment  of  the  bony 
fragments  be  made. 

The  time  of  setting  a  fracture  in  relation  to  the 
time  of  the  occurrence  of  the  injury  is  a  factor  of 
prime  importance.  This  was  well  shown  by  many 
instances  of  suture  of  simple  transverse  fractures  of 
the  patella  by  open  operation  either  performed  or 
witnessed  by  the  author.  In  patients  operated  upon 
very  soon  after  fracture,  the  fragments  could  be 
drawn  together  and  held  in  position  by  a  very  slight 
force.  After  delay,  however,  the  fragments  were 
difficult  to  approximate  and  it  required  a  stout  suture 
to  hold  them  together.  The  very  early  operation 
gave  to  the  surgeon  an  extended  choice  of  character 
of  suture ;  procrastination  gi-eatly  limited  that  choice. 

Upon  the  same  principle  the  early  treatment  by  the 
surgeon  (the  earlier  the  better)  enables  him  to  ad- 
just the  broken  long  bone  in  position,  especially  in 
fractures  of  the  shaft  of  the  femur.  The  illustrations 
(Plate  XVIII)  show  a  sample  of  simple  fracture  of 
the  lower  third  of  the  femur  of  greatest  obliquity 
treated  very  soon  after  fracture  in  which  the  union 


PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS      23 

of  the  broken  bone  was  obtained  in  best  position. 
Traction  easily  restored  the  length  of  the  limb.  On 
the  other  hand,  in  an  instance  of  mal-union  with 
over  four  inches  of  shortening,  the  most  forcible  ef- 
forts at  reduction,  which  were  made  immediately  after 
a  refracture,  only  slightly  diminished  the  shortening 
of  the  limb.  The  soft  parts,  muscles,  tendons  and  es- 
pecially the  fibrous  skeleton  of  the  thigh  had  grown 
in  accommodation  to  the  new  condition  of  shorten- 
ing of  the  limb  and  the  contractures  could  not  be  cor- 
rected by  sudden  and  great  tractive  efforts.  It  is  in 
such  instances  that  long-continued  traction  would  ap- 
pear to  be  allowable  in  an  attempt  to  correct  the  con- 
firmed shortening. 

The  illustration  (Plate  XVIII)  shows  further  the 
capacity  of  the  immovable  apparel  to  maintain  ex- 
tension and  counter-extension  for  a  length  of  time 
sufficient  to  achieve  union  in  perfect  position  of  the 
fragments.  That  the  immovable  plaster-of-Paris 
splint  does  exert  extension  and  counter-extension  was 
well  shown  in  an  instance  witnessed  by  the  author 
in  which  the  splint  was  light  and  weak,  no  tin 
strips  having  been  used,  and  when  the  extension  by 
the  compound  pulleys  was  relaxed  while  the  splint 
was  green  and  soft,  it  telescoped  at  the  site  of  the 
fracture  to  the  extent  of  the  amount  of  the  shorten- 
ing. Extension  by  the  compound  pulleys  was  im- 
mediately reapplied,  the  telescoping  of  the  splint 
at  the  site  of  fracture  was  removed,  the  splint  was 
made  of  due  strength  and  a  satisfactory  union  of  the 
fragments  was  obtained. 

The  usual  controlling  local  condition  is  the  swell- 


24       PRINCIPLES    OF   TREATMENT    OF   BROKEN    LIMBS 

ing.  "While  it  is  true  that  the  plaster-of-Paris  splint 
may  be  applied  at  any  time  irrespective  of  the  degree 
of  swelling,  it  can  only  be  used  as  a  continued  or 
permanent  apparel  developing  its  maximum  effi- 
ciency, while  the  size  of  the  limb  remains  compara- 
tively stationary.  A  confining  and  constricting 
bandage  has  little  control  over  a  rapidly  increasing 
swelling.  Certain  necessitous  circumstances  may  be 
conceived  and  do  occur,  especially  in  fractures  of  both 
bones  of  the  leg,  when  the  application  of  the  splint 
is  imperatively  demanded,  notwithstanding  the  pres- 
ence of  advancing  swelling. 

If  the  swelling  be  acute  and  increasing,  the  applied 
splint  must  immediately  be  cut  open  and  eased  or 
the  constricted  limb,  perhaps  the  life  of  the  patient, 
will  be  sacrificed.  On  the  other  hand,  if  a  consider- 
able swelling  be  rapidly  subsiding,  the  splint  will 
soon  be  a  loose  fit  and  ineffective  and  need  re- 
application.  In  either  instance  the  splint  as  applied 
will  be  only  a  temporary  apparel,  the  maintenance 
of  its  efficiency  with  safety  requiring  successive  re- 
applications. 

If  the  trained  judgment  assures  the  surgeon  that 
the  swelling  will  be  slight  and  the  changes  in  the 
size  of  the  limb  negligible,  the  splint  may  be  applied 
as  a  permanent  fixation  apparel  very  soon  after  the 
occurrence  of  the  fracture — the  sooner  the  better. 
Generally,  however,  the  elective  period  of  its  appli- 
cation as  a  permanent  apparel  is  that  of  greatest 
safety  consistent  with  efficiency,  namely,  when  the 
swelling  has  passed  its  maximum  and  in  recession  has 
reached  a  comparatively  stationary  limit,  which  usu- 


PRINCIPLES   OF  TREATMENT   OF   BROKEN   LIMBS      25 

ally  is  a  matter  of  a  few  days  after  the  receipt  of  the 
injury,  the  limb  meanwhile,  of  course,  having  been 
under  continual  extension  with  weight  and  pulley. 

The  amount  of  shortening  of  the  limb  from  the 
fracture  is  ascertained  by  carefully  made  measure- 
ments. In  measuring  the  limb  the  operator  avoids 
prejudice  and  deceiving  himself  by  having  the  blank 
side  of  the  measuring-tape  turned  toward  him.  He 
measures  from  the  anterior  superior  spine  of  the 
ilium  to  the  tip  of  the  inner  malleolus,  the  patient's 
pelvis  meanwhile  being  perfectly  squared,  so  that 
an  imaginary  line  drawn  transversely  through  the  an- 
terior superior  spines  of  the  ilia  meets  the  median 
longitudinal  plane  of  the  body  at  a  right  angle.  For 
confirmation,  the  measurements  are  repeated.  Not 
all  surgeons  are  capable  of  making  reasonably  exact 
measurements.  One  prominent  surgeon  known  to 
the  writer  would  commit  gross  errors;  the  amount 
of  his  personal  error  was,  indeed,  sometimes  as  great 
as  the  amount  of  the  shortening  to  be  measured. 
With  such  errors  inherent  in  the  personal  instru- 
ment the  measurements  were  of  course  fallacious. 

The  patient  is  then  prepared  for  ansesthesia.  In- 
asmuch as  the  degree  of  swelling  is  a  large  factor 
affecting  the  mechanical  efficiency  of  the  splint,  the 
limb  should  at  all  times  be  carefully  guarded  against 
a  disturbance  of  the  soft  parts.  While  the  use  of  an 
anaesthetic  is  highly  desirable,  it  is  not  absolutely 
essential.  With  old  and  very  feeble  patients  a  stimu- 
lant may  be  used  instead.  The  writer  has  known 
his  skilful  and  rapidly  working  assistant  to  complete 


26       PRINCIPLES    OF    TREATMENT    OF    BROKEN    LIMBS 

the  whole  operation  in  a  most  excellent  manner  in 
less  than  half  an  hour. 

The  fractured  limb  should  be  most  carefully  pro- 
tected against  injury  preparatory  to  the  administra- 
tion of  the  ansesthetic.  Temporary  splints  should 
be  applied  and  extension  meanwhile  maintained.  In 
addition  assistants  should  safeguard  the  patient,  a 
particularly  trustworthy  one  having  constant  charge 
of  the  broken  thigh.  The  patient  when  anaesthetized 
to  complete  relaxation  should  be  held  continuously  in 
the  same  degree  of  ansesthesra  throughout  the  opera- 
tion. This,  like  all  well-conducted,  important  and 
complicated  surgical  operations,  should  be  constantly 
supervised  and  coordinated  by  the  operating  surgeon. 

The  patient  being  fully  under  anaesthesia,  the 
operator  removes  all  dressings  from  the  limb,  an 
assistant,  of  course,  constantly  maintaining  manual 
extension.  Other  things  being  equal,  the  operation 
to  be  well  done  should  be  speedily  done.  Even  min- 
utes should  be  economized.  In  the  complex  operation 
which  we  are  describing,  careful  forethought  and 
method  in  executing  the  different  steps  of  procedure 
will  in  the  total  economize  the  time  and  shorten 
the  period  of  ansesthesia.  This  is  all  the  more  desir- 
able since  it  is  not  necessary  to  give  time  for  the 
setting  of  the  plaster-of-Paris,  under  the  anaesthetic, 
the  fixation  of  the  fragments  being  immediately  ac- 
complished by  the  action  of  the  tin  strips  when 
bandaged  in  position. 

A  transverse  mark  is  made  upon  the  skin  above 
the  inner  malleolus  of  the  injured  limb,  which  will 


PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS      27 

serve  as  a  point  in  measuring  to  correct  the  shorten- 
ing of  the  limb. 

The  protective  covering  of  thin  blanket  or  other 
material  is  carefully  slid  beneath  the  patient.  One 
free  edge  of  the  material  which  extends  a  short  dis- 
tance beyond  the  injured  limb  is  cut  to  conform  to 


Fig.  2. — Plan  of  Cutting  Blanket  Covering  of  Thigh  in  Frac- 
ture of  Shaft  of  Femur. 


the  middle  of  its  external  surface  (Fig.  2).  This 
is  done  by  first  making  a  number  of  guiding  cuts  in 
the  edge  of  the  blanket.  Beginning  near  the  ankle, 
with  one  hand  the  flap  of  blanket  is  held  against 
the  middle  line  of  the  external  aspect  of  the  limb 
and  is  then  cut  with  scissors  down  to  that  point. 
At  intervals  of  a  few  inches  similar  cuts  are  made 
in  the  blanket  along  the  whole  length  of  the  limb 


28      PRINCIPLES   OF  TREATMENT   OF   BROKEN   LIMBS 

and  that  portion  of  the  pelvis  that  is  to  be  covered. 
The  superfluous  blanket,  as  shown  by  the  guiding 
marks,  is  cut  away  till  the  edge  of  the  blanket,  per- 
haps with  a  little  trimming,  can,  when  brought  into 
position,  be  made  to  reach  to  the  middle  of  the 
external  aspect  of  the  limb  throughout  the  whole 
length  to  be  covered.  The  patient's  healthy  thigh  is 
flexed  at  a  right  angle  with  his  body,  and  the  other 
portion  of  blanket  is  cut  diagonally  from  above 
downward  to  a  point  opposite  the  anus.  This  cut  is 
so  made  that  the  portion  of  blanket  above  the  cut 
may  be  brought  around  the  pelvis  anteriorly  and 
temporarily  held  in  position  with  a  single  pin. 

The  lower  or  thigh  portion  of  blanket,  below  the 
transverse  cut,  is  brought  across  the  inner  and  an- 
terior surfaces  of  the  injured  limb,  especial  care  being 
taken  to  cover  the  groin  and  perineum.  This  por- 
tion of  blanket  is  trimmed  to  guiding  cuts,  as  was 
the  case  with  that  covering  the  posterior  and  outer 
surfaces  of  the  limb.  The  blanket  covering  the 
inner  and  anterior  aspects  of  the  limb  overlaps  that 
covering  the  posterior  and  outer  aspects,  the  fold 
thus  formed  lying  along  the  external  and  less  im- 
portant aspect  of  the  limb,  and  is  pinned  in  posi- 
tion beginning  at  the  ankle.  The  loose  edge  of  the 
fold  thus  placed  does  not  obstruct  bandaging,  but 
is  easily  fastened  in  position  by  the  successive  turns 
of  the  bandage.  It  is  better  to  fasten  the  protective 
covering  by  common  pins  than  with  needle  and 
thread.  Little  changes  may  then  be  made  to  make 
the  perfect  fit  and  the  pins  may  be  removed  as  the 
turns  of  bandage  fasten  the  covering  in  position. 


PRINCIPLES    OF   TREATMENT    OF    BROKEN    LIMBS      29 

The  foot  need  not  be  covered  till  the  splint  is  fin- 
ished but  during  the  operation  the  blanket  for  cover- 
ing the  foot  may  be  left  loose  and  turned  back 
from  the  ankle,  out  of  the  way.  The  protective 
covering  of  the  thigh  and  pelvis  has  been  adapted 
while  the  patient  has  been  lying  in  bed  under 
anaesthesia,  the  assistant  meanwhile  preserving  the 
manual  extension  upon  the  limb;  it  having  been  so 
snugly  and  neatly  applied  that  the  outline  of  the 
limb  has  not  been  obscured  or  changed.  The  pa- 
tient is  now  ready  to  be  placed  upon  the  special 
apparatus  necessary  for  extension  and  counter-ex- 
tension to  facilitate  the  construction  of  the  splint. 
It  will  be  observed  that  the  power  (the  com- 
pound pulleys)  is  located  between  two  fixed  points, 
the  two  inserted  screw-eyes,  the  one  from  which 
extension  is  made,  and  the  other,  the  fixed  point  of 
counter-extension.  The. patient  is  not  so  immovably 
fixed  upon  the  apparatus  but  he  may  shift  from 
position.  He  is  so  conditioned,  however,  that  for  a 
sufiicient  though  brief  time  he  may  be  held  in  the 
desired  position  of  best  adjustment  of  the  frag- 
ments. The  assistant  exerts  control  over  the  upper 
fragment  through  acting  upon  the  long  arm  of  the 
lever  resting  upon  the  perineal-bar  as  a  fulcrum. 
The  same  assistant  controls  the  rotation  of  the 
lower  fragment.  The  surgeon  avails  himself  of  all 
helps  to  secure  correct  adjustment  of  the  frag- 
ments, that  is,  he  coordinates  all  the  elements  nec- 
essary to  secure  that  end,  and  then,  while  the  pa- 
tient is  in  position  of  election,  quickly  immobilizes 
the  fragments. 


30       PEINCIPLES    OF   TREATMENT   OF   BROKEN    LIMBS 

The  surgeon  locates  an  imaginary  vertical  plane 
cutting  the  bed  at  a  right  angle  at  about  the  middle 
of  its  length,  which  may  be  designated  the  plane 
of  counter-extension.  (See  Ground  Plan,  Fig.  3.) 
In  this  plane,  beneath  the  edge  of  the  bed,  is  in- 
serted at  a  slight  angle  in  the  floor  a  strong  screw- 


FiG.  3. — Ground  Plan  of  the  Position  of  the  Patient  upon  the 
Apparatus  in  the  Application  of  a  Plaster-of-Paris  Splint  in 
the  Rapid  Setting  of  a  Fracture  of  the  Shaft  of  the  Femur. 
No.  1  is  the  median  plane  of  the  body.  No.  2  is  the  plane 
of  counter-extension.     No.  3  is  the  plane  of  extension. 

eye  which  constitutes  the  fixed  point  of  counter- 
extension.  The  small  piece  of  gas-pipe  fitting  into 
the  upper  end  of  the  perineal-bar  serves  well  in 
inserting  the  screw-eye  into  the  floor.  The  movable 
tripod,  minus  the  smaller  pipe,  to  be  inserted  later 
into    the    upper    end    of    the    perineal-upright,    is 


PBINCIPLES    OF   TREATMENT   OF   BROKEN    LIMBS      31 

brought  near  the  edge  of  the  bed,  the  rear  leg  ex- 
tending under  the  bed,  being  located  in  the  plane 
of  counter-extension  three  or  four  inches  from  the 
inserted  screw-eye;  the  other  two  legs  of  the  tripod 
(forward  legs)  are  placed  equidistant  from  this 
plane,  on  either  side  respectively.  A  rather  heavy 
copper  wire  is  caught  at  its  middle  over  the  screw- 
eye  in  the  floor  and  then  very  coarsely  twisted  to- 
gether till  it  reaches  the  upper  surface  of  the  centre 
block  of  the  tripod.  The  ends  of  wire  are  wrapped 
about  the  upright  perineal-bar  in  opposite  direc- 
tions and  made  fast  by  twisting  (see  Frontispiece). 
By  means  of  this  twisted  wire  the  perineal-upright 
is  hitched  fast  to  the  screw-eye  and  is  constituted 
an  unyielding  resistance  of  counter-extension.  In 
other  words,  the  fixed  point  for  counter-extension 
is  transferred  from  the  screw-eye  in  the  floor  to 
the  perineal-bar  at  the  place  of  bearing  of  the 
perineum.  By  pulling  upon  the  perineal-bar  any 
slack  in  the  wire  is  removed  by  stretching,  and 
the  forward  legs  of  the  tripod  which  oppose  a 
counter-resistance  under  extension  are  made  to 
stand  squarely  upon  the  floor. 

The  principal  assistant,  always  continuing  his 
extension  upon  the  injured  thigh,  seizes  the  pa- 
tient by  both  ankles  while  the  ansesthetizer  grasps 
him  by  the  shoulders  and,  acting  in  concert,  under 
supervision  of  the  surgeon,  they  pivot  the  patient 
upon  the  bed  bringing  the  sound  limb  first  toward 
the  perineal-bar.  The  sound  thigh  is  sufficiently 
flexed  that  it  may  be  lifted  over  the  end  of  the  bar 
and  the  patient  so  placed  in  position  that  the  median 


32       PRINCIPLES    OF   TREATMENT    OF   BROKEN    LIMBS 

longitudinal  plane  of  his  body  shall  be  carried  as 
far  as  possible  in  the  direction  of  the  uninjured 
side,  at  the  same  time  being  maintained  parallel  to 
the  plane  of  counter-extension. 

The  purpose  of  this  is  to  increase  the  leverage 
upon  the  upper  fragment  when  traction  is  made 
upon  the  uninjured  limb,  the  perineal-bar  acting  as 
the  fulcrum  upon  which  the  pelvis  may  be  tilted. 
The  further  the  median  longitudinal  plane  of  the 
body  is  crowded  over  in  the  direction  of  the  un- 
injured side  the  greater  will  be  the  leverage  and 
command  over  the  upper  fragment.  Added  to  this 
advantage,  the  pressure  will  be  away  from  the 
median  line  of  the  perineum,  the  urethra  thus  es- 
caping, and  furthermore,  a  less  total  pressure  will 
be  exerted  upon  the  perineum. 

The  patient  having  been  properly  placed  in  posi- 
tion it  now  becomes  an  additional  duty  of  the  an- 
aesthetizer,  under  supervision  of  the  operator  of 
course,  to  assist  in  the  preservation  of  the  patient 
in  correct  position. 

The  smaller  pipe  fitting  into  the  upper  end  of 
the  perineal-bar  is  then  fitted  into  place.  The  bed 
is  pushed  back  from  the  perineal-bar  just  far  enough 
to  give  working  space  about  the  patient's  pelvis. 
The  copper  wire,  previously  attached  to  the  perineal- 
bar,  is  carried  backward  along  the  sacrum  and  the 
ends  are  brought  upward  along  each  side  of  the 
pelvis  and  attached  over  the  tip  of  the  horizontal 
piece  of  the  smaller  pipe  of  the  perineal-bar  over- 
hanging the  pelvis. 

The  purpose  of  this  wire  is  not  so  much  to  sus- 


PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS      33 

pend  the  pelvis  as  to  prevent  its  displacement  by 
partial  rotation  on  a  longitudinal  axis  of  the  body 
projected  through  it  to  its  bearing  against  the 
perineal-bar.  It  is  therefore  a  guy-wire.  The  pel- 
vis is  sustained  clear  of  the  bed  by  the  patient's 
body  resting  upon  the  bed  and  by  being  held  firmly 
in  its  bearing  against  the  perineal-bar  under  the 
force  of  extension.  Ample  working  room  may  be 
gained  about  the  pelvis  by  pushing  the  bed  back 
from  the  perineal-bar,  without  disturbing  the  ad- 
justed position  of  the  patient  upon  the  apparatus. 
A  clove-hitch  made  sufficiently  strong  from  a  folded 
bandage  is  now  attached  to  the  naked  ankle  above 
the  malleoli.  The  ends  of  the  bandage  are  tied  into 
a  loop  into  which  may  be  caught  one  of  the  hooks 
of  the  compound  pulleys.  The  clove-hitch  may  be 
so  adjusted  to  the  ankle  that  it  will,  in  large  de- 
gree, control  the  eversion  of  the  lower  fragment. 

The  fixed  point  from  which  extension  is  to  be 
exerted  is  constituted  by  a  strong  screw-eye  which 
is  screwed  into  the  woodwork  of  the  room  at  a  point 
where  the  prolonged  long  axis  of  the  broken  limb 
under  extension  will  touch. 

Before  the  operation  has  been  commenced,  the 
bed  has  been  placed  in  proper  position  in  reference 
to  the  mechanical  requirements  of  the  operation  and 
the  screw-eyes  inserted  in  proper  position. 

As  shown  in  the  Frontispiece,  the  principal  assist- 
ant, comfortably  seated,  with  one  hand  controls 
the  rotation  of  the  lower  fragment  by  so  holding  the 
ankle  that  the  foot  is  somewhat  inverted;  at  the 
same   time   grasping   the    ankle    of   the    uninjured 


34s      PRINCIPLES   OF   TREATMENT    OF    BROKEN    LIMBS 

limb  he  exerts  sufficient  traction  to  hold  the  pelvis 
in  position  and  control  the  upper  fragment.  The 
importance  of  so  placing  the  pelvis  upon  the  peri- 
neal-bar  as  a  fulcrum  as  to  favor  the  leverage  upon 
the  upper  fragment  has  been  explained.  Some- 
times a  clove  hitch  is  attached  to  the  ankle  of  the 
uninjured  limb  and  connected  to  the  extension  upon 
the  other  limb,  but  with  a  trained  skilful  assistant 
exerting  control  over  the  upper  fragment  this  fea- 
ture of  practice  may  be  generally  dispensed  with. 

We  may  pass  in  review  the  steps  of  the  procedure 
to  the  present  stage  of  the  operation: — 

The  patient  lying  upon  his  bed  has  been  pro- 
tected from  self -in  jury  during  the  administration 
of  the  anaesthetic  by  having  temporary  splints  ap- 
plied to  the  injured  limb. 

The  ansesthetic  has  been  given.  If  the  patient 
is  old  and  feeble  a  stimulant  may  be  given  instead. 

The  temporary  splints  have  been  removed  and 
the  limb  and  pelvis  covered  with  a  protective  of 
thin  blanket  or  other  material. 

Imaginary  planes  have  been  located  for  the  guid- 
ance of  the  surgeon  in  placing  the  patient  upon  the 
special  apparatus. 

The  fixed  points  for  extension  and  counter-ex- 
tension have  been  established  and  the  special  thigh 
setting  apparatus  has  been  placed  in  position. 

The  patient  has  been  placed  upon  the  apparatus 
and  the  extension  by  means  of  compound  pulleys 
has  been  substituted  for  manual  extension  which 
has  hitherto  been  constantly  exerted. 

All  through  the  procedures  the  injured  limb  has 


PRINCIPLES    OF   TREATMENT   OF   BROKEN    LIMBS      35 

been  disturbed  as  little  as  possible  so  as  not  to  ex- 
cite an  increase  of  swelling. 

Enough  extension  is  for  the  time  exerted  through 
the  compound  pulleys  to  straighten  the  thigh  and 
take  out  most  of  the  sag  at  the  place  of  fracture. 
All  through  the  operation  the  surgeon  strictly  co- 
ordinates his  assistants,  supervising,  with  a  full 
sense  of  his  responsibility,  every  feature  of  the 
operation.  All  preparations  that  forethought  could 
suggest  have  been  made  so  that  there  may  be  no 
delay  in  the  progress  of  construction  of  the  splint. 

As  in  the  case  of  the  leg  splint,  a  foundation 
layer  of  plaster-of-Paris  bandage  is  applied  to  the 
leg,  thigh  and  about  the  pelvis  covering  the  limits 
of  the  prospective  splint  from  the  ankle  to  the 
pelvic  limit.  Especial  care  is  bestowed  in  the  mak- 
ing of  the  spica  at  the  pelvis.  One  layer  of  band- 
age even  when  closely  imbricated  does  not  make  a 
sufficiently  firm  foundation  for  the  tin  strips  es- 
pecially with  the  yielding  soft  tissues  about  the 
groin.  There,  and  at  any  other  place  where  the 
underlying  soft  tissues  are  too  yielding  to  give  a 
good  basis  for  the  tin  strips,  either  strips  of  plaster- 
of-Paris  bandage  folded  in  reverses,  or  pieces  of 
blanket  saturated  with  a  thin  cream  of  plaster-of- 
Paris  and  cut  to  form  will  remedy  the  weaknesses. 
Into  the  foundation  layer,  as  in  the  construction  of 
the  leg  splint,  a  small  amount  of  moistened  plaster 
is  rubbed,  smoothing  all  folds  of  bandages  and 
sticking  them  together.  This  foundation  layer, 
when  completed,  leaves  the  outline  of  the  limb  sharp 
and  distinct. 


36       PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMES 

The  pelvic  portion  of  the  splint  should  not  be 
extended  too  high.  The  author  has  sometimes  seen 
it  made  so  high  as  to  infringe  upon  the  lower  ribs, 
thus  greatly  hampering  the  movements  of  the  pa- 
tient, who  could  not  even  sit  up  in  comfort.  The 
pelvic  portion  of  the  splint  is  for  the  purpose  not 
only  of  securing  a  hold  upon  the  upper  fragment, 
but  also  for  the  purpose  of  controlling  the  rotation 


Fio.  4. — Construction  of  Pelvic  Portion  of  Thigh  Splint  (rear 
view)  in  Fracture  of  the  Shaft  of  the  Femur. 

(generally  in  eversion)  of  the  lower  fragment.  The 
proper  construction  is  shown  in  Fig.  4. 

The  weak  places  where  the  splint  is  most  likely 
to  give  way  from  the  wear  of  weeks  are  about  the 
groin,  the  buttocks,  and  the  posterior  aspect  of  the 
thigh  and  leg.  In  construction,  the  strength  of  the 
texture  of  the  splint  is  proportioned  somewhat  to 
the  closeness  of  the  imbrications  of  the  folds  of 
bandage. 

The  tin  strips  for  use  in  fractures  of  the  shaft  of 
the  femur  are  made  no  wider  but  longer  than  need 


PRINCIPLES    OF   TREATMENT   OF    BROKEN    LIMBS      37 

be  the  case  for  fractures  of  the  leg;  otherwise  they 
are  of  the  same  construction.  They  are  easily  made 
longer  by  soldering  two  or  more  strips  together  at 
their  overlapping  ends.  About  seven  or  eight  strips 
are  used,  and  they  are  disposed  in  the  principal  longi- 
tudinal planes  of  the  limb  as  in  the  case  of  setting 
the  leg  fracture,  described.  To  reiterate,  the  tin 
strips  operate  as  a  resistance  to  forces  by  reason 
of  their  not  changing  in  length,  either  by  shorten- 
ing or  lengthening  when  nicely  adapted  to  the  con- 
tour of  the  surface  of  the  limb  and  firmly  held  in 
position  between  layers  of  bandage.  They  resist 
forces  tending  to  displace  the  fragments  in  shorten- 
ing of  the  limb  or  in  angailar  deformity,  rotation 
or  any  other  mode  of  displacement  that  can  be 
resisted  from  the  surface,  operating  upon  the  bony 
fragments  through  the  yielding  medium  of  the  soft 
parts:  they  also  develop  some  resistance  by  virtue 
of  their  width,  though  very  narrow. 

\Miile  they,  no  doubt,  add  to  the  strength  of  the 
constructed  plaster-of-Paris  splint,  their  use  was 
not  designed  for  that  purpose.  They  are  them- 
selves the  splint,  constituting  the  resistance  to  forces 
tending  to  move  the  fragments  in  relation  to  each 
other,  immobility  ^vithin  limits  being  the  essential 
attribute  of  all  methods  of  treatment.  Their  action, 
immediately  operative ^  is  rendered  more  surely  per- 
manent by  the  material  used  in  the  bandages  by 
which  their  primary  and  essential  fimction  is  con- 
tinued. The  plaster-of-Paris  splint  in  its  construc- 
tion is  an  infinitude  of  lines  of  resistance  coming 
into  practical  operation  through  the  hardening  of 


38       PRINCIPLES   or   TREATMENT   OF   BROKEN    LIMBS 

the  plaster,  which  requires  the  lapse  of  a  variable 
period  of  time ;  the  tin  strips  develop  their  resistance 
immediately. 

To  proceed  with  our  operation,  tin  strips  are 
placed  on  either  side  of  the  anterior  median  line 
and  in  the  posterior  median  line  and  side  strips, 
internal  and  external,  midway  between  them^ 
Added  strips  are  placed  anteriorly  and  posteriorly 
between  the  median  and  lateral  strips.  They  ex- 
tend from  the  ankle  to  a  line  far  beyond  the  de- 
signed upper  pelvic  margin  of  the  splint.  They 
are  held  in  position  by  a  few  turns  of  the  bandage 
at  the  ankle  till  their  correct  general  course  up 
the  limb  is  assured.  The  tin  strips  are  firmly  band- 
aged home  to  their  foundation  as  far  as  the  site 
of  fracture.  During  the  whole  bandaging  the  ex- 
posed portions  of  the  strips  are  allowed  to  hang 
free  and  uncontrolled  that  they  may  adapt  them- 
selves perfectly  to  the  contour  of  the  limb. 

When  they  have  been  bandaged  firmly  in  rela- 
tion to  the  lower  fragment  as  far  as  the  site  of 
fracture,  the  surgeon  carefully  reviews  the  situa- 
tion. He  makes  sure  that  the  patient  is  in  every  re- 
spect in  correct  position  upon  the  apparatus.  With 
his  tape  he  measures  from  the  anterior  superior  spine 
of  the  ilium  to  the  mark  made  upon  the  skin  of  the 
ankle,  at  the  same  time  directing  the  assistant  hold- 
ing the  rope  of  the  compound  pulleys  to  make 
sufficient  extension  to  overcome  the  known  amount 
of  shortening  of  the  limb;  it  is  well  to  even  over- 
correct  the  shortening.  He  carefully  regards  the 
outline  of  the  thigh  to  see  that  all  sag  at  the  place 


PRINCIPLES   OF   TREATMENT   OF   BROKEN    LIMBS      39 

of  fracture  is  removed,  and  that  the  normal  outline 
of  the  thigh  is  restored,  using  any  manipulation 
that  may  be  necessary  to  secure  that  object.  All 
ihis  is  done  with  a  strict  regard  to  the  preservation 
of  the  patient  in  correct  position  upon  the  apparatus. 

With  a  final  word  of  warning  to  his  assistants  to 
be  alert  in  the  performance  of  their  duties,  he  rap- 
idly, in  a  few  seconds,  by  figure  of  eight  turns  of 
the  bandage,  firmly  bandages  the  tin  strips  home 
to  their  foundation  and  in  relation  to  the  upper 
fragment.  By  this  rapidly  executed  manoeuvre  the 
fragments  are  fixed  in  their  adjusted  relation  to 
each  other.  He  continues  his  bandaging  to  the 
upper  pelvic  margin  of  the  splint,  where  he  re- 
verses the  tin  strips  sharply,  bringing  them  down 
^gain  upon  the  splint  (see  Plate  V,  lower  figure) 
in  a  direction  downward  and  diagonally  outward. 
Most  of  the  reversed  strips  reach  down  past  the 
site  of  fracture.  The  anterior  strips  he  cuts  short 
l)efore  the  knee-joint  is  reached.  The  posterior 
strips  and  some  of  the  lateral  ones  reach  down  past 
ihe  knee-joint  upon  the  calf  of  the  leg.  The  re- 
versed strips  are  not  allowed  to  interfere  with  each 
other;  they  hang  free  and  uncontrolled  and  are 
bandaged  home  from  above  downward,  commenc- 
ing at  the  upper  pelvic  margin  of  the  splint.  The 
fixation  of  the  adjusted  fragments,  although  the 
splint  is  wet  and  soft,  has  been  accomplished  under 
ihe  best  conditions.  The  guides  for  correct  adjust- 
ment have  not  at  any  time  been  obscured  or  im- 
paired. 

The  surgeon  may  now  proceed  to  strengthen  the 


40      PRINCIPLES   OF  TREATMENT   OF   BROKEN   LIMBS 

splint  without  any  fear  of  disturbing  the  adjusted 
fragments,  now  already  fixed  in  their  relation  to 
each  other.  A  little  experience  will  teach  just  how 
much  and  where  the  splint  should  be  reinforced 
posteriorly  to  stand  a  month's  or  six  weeks'  wear. 
A  skilful  hand  may  so  manipulate  the  plaster-of- 
Paris  bandage  in  making  reverses  to  give  all  the 
added  strength  in  places  otherwise  weak,  that  is 
required,  or,  pieces  of  thin  blanket  saturated  with 
plaster-of-Paris  cream  and  cut  to  form,  may  be 
bandaged  in  position.  The  protective  covering  of 
blanket  extending  beyond  the  pelvic  margin  of  the 
splint  is  then  trimmed  to  within  two  or  three  inches 
of  the  margin  of  the  splint,  turned  back  upon  it 
as  a  cuff,  and  retained  in  position  by  plaster  band- 
ages and  finally,  while  quite  wet,  moistened  plaster 
may  be  rubbed  into  the  entire  surface  of  the  splint. 
This  finishing  coat  should  not  be  too  thick,  nor 
should  the  smoothing  process  be  too  long  persisted 
in,  lest,  to  repeat,  the  initial  set  of  the  plaster  be 
interfered  with,  and  the  plaster  "flour." 

The  construction  of  the  splint  having  been  thus 
far  completed,  extension  is  relaxed,  the  compound 
pulleys  disconnected,  and  the  clove-hitch  removed 
from  the  ankle.  The  protective  covering  having 
previously  been  cut  to  form,  the  foot  and  ankle  are 
speedily  covered,  the  covering  of  the  foot  having 
been  so  well  arranged  that  it  may  be  retained  by  a 
single  common  pin.  This  covering  is  so  adapted 
that  the  instep  and  tendo  Achillis  are  covered  by 
a  double  layer. 

In  bandaging,  care  is  exercised  that  the  dorsal 


[PRINCIPLES   OF  TREATMENT   OF   BROKEN   LIMBS      41 

face  of  the  instep,  the  point  of  the  heel  and  the 
skin  over  the  tendo  Achillis  are  not  subjected  to 
an  excess  of  pressure.  From  the  lack  of  exercise 
of  skill  in  this  regard  the  author  has  seen  an  ulcer 
upon  the  heel  give  more  trouble  than  the  cure  of 
the  fracture  itself. 

It  is  always  to  he  remembered  in  bandaging  that 
the  greatest  support  to  the  circulation  by  compres- 
sion is  to  be  given  to  the  periphery  of  the  body,  the 
strength  of  compression  lessening  as  it  approaches 
the  circulatory  centre.  The  foot  may  be  simply 
bandaged  with  an  ordinary  dry  bandage,  but  the 
author's  preference  and  general  practice  has  been 
to  use  the  plaster-of-Paris  bandage. 

Some  surgeons  in  applying  splints  that  include 
the  foot  have  been  at  great  pains  to  immobilize  the 
foot  at  right  angles  with  the  leg.  The  reasons  for 
this  practice  seemed  to  the  author  to  lack  force. 
It  is  an  unnatural  position  of  the  foot  and  there 
is  a  greater  risk  involved  from  unequal  and  undue 
pressure.  It  has  never  been  practiced  by  the  author 
whose  results  have  always  been  without  the  com- 
plication of  accidents,  and  perfectly  satisfactory. 

The  inclusion  of  the  foot  and  ankle  in  the  con- 
structed splint  while  not  absolutely  necessary,  is 
generally  advisable.  The  construction  of  the  splint 
upon  the  foot  and  leg,  preliminary  to  the  making 
of  the  thigh  splint  should  never  be  practiced.  When 
extension  is  made  from  the  leg  piece  of  splint  al- 
ready applied  it  is  liable  to  slip  and  the  leg  splint 
will  then  act  as  a  partially  withdrawn  tight  fitting 
boot,  causing  undue  pressure  at  certain  places,  with 


42      PRINCIPLES   OF  TREATMENT   OF   BROKEN   LIMBS 

great  discomfort  and  probably  troublesome  sloughs. 
Neither  should  the  toes  ever  be  covered  in,  as  the 
author  has  sometimes  witnessed.  The  exposed  toes 
are  the  tell-tale  of  the  condition  of  the  circulation. 
They  should  be  always  left  free. 

The  patient  is  now  ready  to  be  freed  from  the 
apparatus.  It  will  have  been  observed  that  while 
upon  the  apparatus  the  patient  has  always  been  in 
the  best  position  for  surgical  functioning,  no  re- 
strictions having  been  imposed  thereon.  At  any 
stage  of  the  operation,  should  necessity  therefor 
have  arisen,  he  could  easily  have  been  freed  from 
the  apparatus.  This  could  have  been  done  in  a 
few  seconds'  time  and  the  patient  re25laced  in  bed 
in  his  original  position.  The  aneesthesia  is  stopped. 
The  heavy  wire  connecting  the  tripod  to  the  screw- 
eye  of  counter-extension  is  untwined;  in  an  emer- 
gency, to  gain  a  few  seconds  of  time,  this  could 
be  cut  with  strong  scissors.  The  guy  wire  con- 
trolling the  rotation  of  the  pelvis,  is  cut  on  either 
side.  The  patient  is  seized  by  the  shoulders  bj^  the 
anassthetizer  and  drawn  a  short  distance  up  on  the 
bed.  While  the  ansesthetizer  holds  the  patient  by 
the  shoulders  and  the  first  assistant  holds  him  by 
the  ankles,  the  tripod,  its  forward  legs  resting  upon 
the  floor,  is  pulled  over,  withdrawing  the  pelvic 
guy-wire  from  the  splint,  and  the  patient  then 
rests  upon  the  bed,  thus  speedily  freed  from  the 
apparatus.  The  two  assistants,  protecting  the  splint 
as  much  as  possible,  turn  the  patient  as  upon  a 
pivot,  back  into  his  original  position  upon  the  bed. 

After  the  splint  has  set  and  hardened,  and  before 


PRINCIPLES   OF  TREATMENT   OF   BROKEN   LIMBS      43 

it  is  dry,  the  surgeon  carefully  inspects  his  work. 
First  of  all,  he  notices  the  character  of  the  circula- 
tion. With  a  snug  fitting  splint  the  toes  may  be 
at  first  a  little  puffy,  but  the  circulation  must  be 
distinct,  bright  and  not  retrograding.  If  com- 
plaint is  made  of  pressure  over  bony  points  it  may 
be  eased  by  compressing  the  splint  between  the 
hands.  Continued  complaints  of  pain  should  never 
be  masked  with  morphine  but  must  receive  respect- 
ful attention,  even  if  it  results  in  the  cutting  down 
of  the  splint.  Under  such  circumstances  the  sur- 
geon will  wish  he  had  moderated  the  pressure  of 
his  bandage  in  the  affected  places,  which  attain- 
ment was  within  the  reach  of  skill.  He  specially 
directs  his  observation  to  the  delicate  tender  tissues 
of  the  perineum.  In  a  well-constructed  splint,  it 
may  happen  that  he  will  be  obliged  to  trim  away 
the  edge  of  the  splint  there,  but  he  should  be  very 
slow  in  taking  away  too  much  splint  and  leaving 
the  tissues  unsupported,  otherwise  they  will  "bag," 
become  congested  and  ulcerate  at  the  margin  of 
the  splint.  At  first  he  may  do  a  little  trimming 
in  the  perineum  down  to  the  blanket  protective 
covering.  On  the  contrary,  it  will  sometimes  hap- 
pen that  he  has  not  carried  his  construction  far 
enough  or,  perhaps,  he  has  cut  away  too  much  of 
the  splint  upon  the  permeum  and  that  the  tissues 
will  bag.  To  correct  these  conditions  and  the  ten- 
dency to  ulceration  he  should  not  cut  away  the 
splint  but  support  the  tissues  with  a  well-applied 
dry  bandage  applied  over  the  splint,  perhaps  even 
slightly   padding  the  concerned   supported   tissues. 


44       PRINCIPLES    OF   TREATMENT   OF    BROKEN    LIMBS 

All  going  well,  the  surgeon  induces  the  patient 
to  move  about  as  soon  as  possible.  The  operation 
has  been  conducted  in  such  a  manner  as  to  irritate 
the  lacerated  soft  tissues  as  little  as  possible  thereby 
forestalling  any  disagreeable  reaction  in  the  way 
of  increased  swelling.  The  compressing  splint  hold- 
ing the  fragments  comparatively  still,  and  with- 
drawing the  injured  muscles  from  functioning,  bene- 
ficently quiets  the  tissues.  At  the  same  time  it 
must  be  remembered  that  a  continued  shrinkage 
in  the  size  of  the  limb  alters  its  physical  and  me- 
chanical relations  to  the  splint,  lessening  the  re- 
sistance of  the  latter  to  forces  tending  to  move  the 
fragments.  Consequently  it  is  desirable,  for  me- 
chanical reasons  alone,  to  induce  the  patient  to 
move  about  so  that  the  ensuing  local  oedema  may 
keep  the  splint  packed  and  efficient  as  a  resistance. 

Within  forty-eight  hours,  perhaps  the  next  day, 
the  patient  is  urged  to  leave  his  bed  to  sit  in  a 
chair  and  be  propped  up  with  pillows.  Very  soon, 
within  a  day  or  two,  he  walks  upon  crutches,  not, 
of  course,  bearing  any  weight  upon  the  injured 
limb.  In  about  a  month,  perhaps  a  little  sooner, 
the  patient  himself  subjectively  knows  that  union 
of  the  fragments  is  well  established.  At  the  end 
of  a  month  or  six  weeks,  the  splint,  pretty  well 
worn,  is  cut  down  anteriorly.  A  strip  is  moistened 
with  water  in  the  anterior  median  line  and  cut  down 
with  a  common  loiife  with  rather  a  coarse  cutting 
edge.  Tin  strips,  as  they  are  encountered,  are  cut 
with  stout  scissors.  Specially  designed  instruments 
to  cut  down  the  splint  are  of  little  worth.     When 


PRINCIPLES    OF   TREATMENT   OF   BROKEN    LIMBS      45 

the  splint  is  removed,  of  course,  great  interest  cen- 
tres in  the  amount  of  shortening  of  the  limb.  Com- 
parative measurements  with  the  healthy  limb  are 
taken  and  recorded. 

When  the  use  of  the  immovable  plaster-of-Paris 
splint  in  the  treatment  of  simple  fractures  of  the 
shaft  of  the  femur  was  much  practiced,  I  think  I 
am  safe  from  contradiction  and  very  moderate  in 
making  the  general  statement,  that  in  expert  hands 
such  treatment  was  at  least  as  effective  in  overcom- 
ing shortening  as  any  other  treatment  then  in  vogue. 
Indeed,  many  times  I  have  found  experts  in  measur- 
ing, fail  to  find  more  than  a  negligible  discrepancy 
between  the  two  limbs,  say  %  or  1/4  of  an  inch. 
And  in  some  few  instances  I  have  heard  an  expert 
declare  his  doubt  that  the  thigh  had  ever  been 
broken  and  that  he  must  have  evidence  that  such 
had  been  the  fact,  when  of  course  it  could  be  amply 
proven  to  have  been  the  case. 

After  the  measurements  have  been  impartially 
taken,  in  the  further  treatment  of  the  limb  the 
splint  is  treated  as  a  movable  one.  It  is  taken  off 
as  much  as  possible  and  used  only  when  necessary 
to  protect  the  limb  against  the  chance  of  accidental 
injurj^  Every  day  the  limb  is  douched  alternately 
with  hot  and  cold  water,  gentl}^  shocked,  and  func- 
tion stimulated  by  the  patient's  exercise  of  his  will 
and  his  own  active  efforts.  Under  such  a  line  of 
treatment  the  stiffness  of  the  joints  rapidly  disap- 
pears, the  union  is  strengthened  and  the  normal 
function  of  the  limb  regained. 

To  overcome  the  stiffness  of  joints  in  the  treat- 


46       PRINCIPLES   OF  TREATMENT   OF   BROKEN    LIMBS 

ment  of  these  injuries,  as  well  as  in  the  more  ag- 
gravated instances  after  the  open  suture  of  frac- 
tures of  the  patella,  the  author  has  never  practiced 
passive  motion.  Overlooking  the  arguments  that 
might  be  made  against  it,  he  will  declare  that  in 
all  instances  the  active  efforts  of  the  patient  under 
the  stimulus  of  the  will  have  been  competent  to  re- 
store full  normal  function  to  the  joint. 

From  his  experience  and  observation  the  author 
avers  that  under  good  treatment  a  non-union  of 
the  fragments  must  be  a  rare  occurrence. 

In  the  instance  of  the  simple  fracture  of  both 
thighs,  sho\^^l  in  Plates  X  and  XI,  two  perineal-bars 
were  mounted  in  the  wooden  tripod  instead  of  one, 
thereby  avoiding  pressure  upon  the  middle  line  of 
the  perineum.  The  lower  limbs  were  brought  to 
the  same  length  and  enclosed  in  splints.  The  con- 
structed splints  were  heavy  and  anchored  the  pa- 
tient inmfiovable  in  bed.  He  at  once  began  to  lose 
appetite  and  strikingly  to  lose  strength.  To  af- 
ford him  a  chance  to  exercise,  the  author  rigged 
for  him  the  suspension  apparatus  shown  in  Plates 
X  and  XI.  The  patient  was  at  once  delighted  with 
it.  Whenever  he  felt  disposed,  which  was  often, 
he  would  swing  himself  clear  of  the  bed  and  exer- 
cise like  an  acrobat.  One  evening  he  suspended 
himself  at  eleven  o'clock  (as  in  Plate  X),  and  after 
exercising  fell  asleep  and  slept  soundly  till  break- 
fast time  next  morning.  He  soon  recovered  his 
appetite  and  rapidly  regained  his  strength.  "While 
undergoing  treatment  he  was  taken  in  the  ambu- 
lance to  Bellevue  Hospital,  where  he  was  exhibited 


PRINCIPLES    OF   TREATMENT   OF   BROKEN    LIMBS      47 

before  the  class  of  students.  He  was  suspended 
from  the  great  dome  of  the  amphitheatre  and  took 
pleasure  in  going  through  his  exercises.  When 
the  splint  was  removed  the  lower  extremities  were 
found  to  be  without  deformity  and,  by  careful  meas- 
urements, of  equal  length.  Soon  after  he  recovered 
function  in  the  fractured  limbs  and  went  to  his 
former  work,   earning  his  livelihood. 

It  has  been  stated  that  the  degree  of  efficiency 
of  the  immovable  plaster-of-Paris  splint  is  related 
to  the  degree  of  compression  of  the  soft  parts.  In 
some  instances,  where  there  has  been  great  injury 
of  the  soft  tissues,  their  tolerance  of  compression 
is  very  slight,  with  the  consequence  of  a  reduced 
efficiency  of  the  resistance  afforded  by  the  splint. 
This  is  generally  the  case  in  compound  fractures, 
and  also  in  some  simple  fractures  where,  in  spite 
of  swelling,  from  special  reasons,  like  imminent  de- 
lirium, the  protection  of  a  splint  is  rendered  neces- 
sary. Inasmuch  as  the  line  of  safety  in  compression 
of  the  soft  parts  must  not  be  transgressed,  it  be- 
comes advisable  to  moderate  the  effect  of  forces 
tending  to  move  or  displace  the  fragments,  which 
is  tantamount  to  increasing  the  resistance  afforded 
by  the  splint,  'and  this  is  accomplished  by  the  sus- 
pension of  the  injured  limb.  The  better  to  un- 
derstand the  principles  of  suspension  embodied  in 
apparatus,  it  will  be  well  to  briefly  trace  the  de- 
velopment of  the  suspension  apparatus  formerly  in 
use  in  Bellevue  Hospital. 

The  most  primitive  contrivance  then  in  use  was 
the  suspension  of  the  limb  in  splints  by  loops  of 


48       PRINCIPLES   OF   TREATMENT   OF   BROKEN    LIMBS 

bandage  from  a  cradle  placed  over  the  limb.  This 
in  a  limited  degree  withdrew  resistance  in  'a  single 
plane,  principally  acting  upon  the  lower  fragment. 

A  very  decided  advance  was  made  by  the  device 
of  Dr.  Van  Wagenen,  a  member  of  the  House 
Staff.  His  contrivance  consisted  essentially  of  a 
wooden  gallows,  made  fast  to  the  foot  of  the  bed. 
Its  flat  horizontal  portion,  overhanging  the  limb, 
contained  two  slots,  each  about  six  inches  long. 
Upon  an  iron  rod  passing  lengthwise  of  each  slot 
travelled  a  pulley  from  which  depended  a  few  inches 
of  rubber  tubing,  which  carried  at  its  lower  end 
another  pulley  whose  plane  of  rotation  was  trans- 
verse to  the  long  axis  of  the  suspended  limb.  The 
limb  in  splint  was  suspended  in  loops  of  rope  which 
ran  over  the  lower  pulleys.  In  its  action,  this 
apparatus  withdrew  resistance  to  motion  in  a  ver- 
tical plane,  and  also  to  rotation  of  the  limb  upon 
its  longitudinal  axis.  In  practice,  however,  the  two 
upper  pulleys  would  often  approach  each  other, 
bringing  the  suspending  loops  of  rope  together, 
sometimes  over  the  wound,  and  the  even  support 
of  the  limb  in  balance  would  be  destroj^ed. 

These  defects,  among  others,  led  the  author  to 
design  the  construction  shown  in  Plate  VI,  which 
in  action  was  very  satisfactory.  A  triangular 
w^ooden  support  was  fastened  to  the  foot  of  the 
bed.  Into  a  socket  in  its  upper  end  was  received 
an  iron  gas-pipe,  which  turned  freely.  The  pipe 
extended  perpendicularly  upward,  and  was  then 
bent  to  extend  horizontally.  Into  its  free  end  was 
received   a   piece   of   smaller   pipe,   which   extended 


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PRINCIPLES  OF   TREATMENT   OF   BROKEN    LIMBS      49 

horizontally  about  six  inches  and  was  turned  ver- 
tically upward  for  a  length  of  about  two  inches. 
This  smaller  pipe  was  held  in  place  by  having  its 
received  portion  bent  a  little  out  of  line,  enough 
to  give  sufficient  friction.  A  pulley,  about  two 
and  a  half  inches  in  diameter,  travelled  freely  upon 
the  smaller  pipe,  being  checked  in  one  direction  by 
the  end  of  the  larger  gas-pipe,  and  in  the  other  by 
the  upturned  end  of  the  smaller  pipe. 

To  the  lower  end  of  the  pulley  from  which  the 
screw  had  been  removed  was  fastened  a  loop  of  a 
few  inches  of  elastic  rubber  tubing.  At  the  lower 
end  of  the  tubing  was  a  strong  hook  fashioned  out 
of  strong  iron  wire.  Inasmuch  as  under  the  strain 
of  constant  use  the  loop  of  rubber  tubing  was  apt 
to  break,  the  weak  point  was  guarded  by  a  safety 
line  of  flexible  braided  wire  picture  cord.  It  was 
fastened  to  the  pulley  above  and  the  hook  below, 
sufficient  slack  being  given  to  allow  full  play  to  the 
elastic  tubing  under  the  weight  of  the  suspended 
limb.  Under  this  arrangement,  the  author  has  known 
the  elastic  tubing  to  break  without  awakening  the 
patient  from  sleep,  the  safety  cord  holding  the  sus- 
pension rigging  intact. 

Into  the  hook  at  the  lower  end  of  the  loop  of  elastic 
was  caught  a  short  length  of  chain  of  pl'ain  coarse 
round  links.  This  chain  was  for  the  purpose  of  ad- 
justing the  elevation  or  depression  of  the  limb.  Into 
one  of  the  lower  links  of  the  chain  was  caught  the 
hook  connected  with  a  square  loop  made  of  rather 
heavy  iron  wire,  which  loop  received  loosely  the 
wooden  bar  from  which  the  limb  was  directly  sus- 


50       PRINCIPLES   OF   TREATMENT   OF   BROKEN    LIMBS 

pended.  The  bar  iVas  of  hard  wood.  On  its  upper 
edge  it  was  grooved  transversely,  near  each  end;  the 
grooves  were  about  one  inch  apart  and  of  a  size  and 
depth  to  receive  easily  the  wire  loops  of  the  pulleys 
over  which  ran  the  ropes  encircling  the  limb  in  splint. 
On  its  lower  edge,  one  side  of  the  centre,  the  bar  had 
cut  into  it  three  or  four  notches,  about  an  inch  apart, 
into  which  could  be  shifted  the  square  iron  wire  loop 
catching  into  the  lower  part  of  the  chain.  The 
wooden  bar  spaced  the  pulleys  carrying  the  suspend- 
ing loops  of  rope  which  could  consequently  be  held 
in  predetermined  position.  The  notches  in  the  upper 
edge  of  the  bar,  at  each  end  permitted  an  accurate 
spacing  of  the  loops  of  rope  and  those  in  the  lower 
edge,  'a  nice  balancing  of  the  suspended  limb. 

The  pulleys  carrying  the  ropes  suspending  the 
limb  were  treated  in  this  way:  The  screw  of  each 
pulley  was  cut  off  flush  with  the  body  of  the  pulley; 
in  its  place  a  square  loop  of  wire  to  slide  back  and 
forth  over  the  wooden  bar  was  fastened  to  the  body 
of  the  pulley,  the  plane  of  the  loop,  of  course,  co- 
inciding with  the  plane  of  the  pulley  wheel;  this 
loop  was  made  sufficiently  large  so  that  when  the 
pulley  hung  in  place  from  the  bar  there  would  be 
left  ample  space  between  the  upper  surface  of  the 
body  of  the  pulley  and  lower  surface  of  the  bar  so 
the  pulley  could  not  only  be  shifted  into  position  in 
different  notches  in  the  bar,  but  might  swing  freely, 
thereby  accommodating  its  plane  of  rotation  to  any 
inclination  of  the  rope,  which,  were  the  pulley  fast 
to  the  bar,  would  ride  off  or  block  the  wheel.  The 
limb  was  suspended  directly  from  the  pulleys  by; 


PRINCIPLES    OF   TREATMENT   OF   BROKEN    LIMBS      51 

loops  of  small  rope  which  rode  easily  in  the  pulley 
grooves.  In  action,  the  limb  was  comfortably  sus- 
pended by  the  encircling  loops  of  rope  which  were 
accurately  spaced,  and  balanced  in  the  best  position. 
The  elevation  or  depression  could  be  regulated  to  a 
nicety  by  the  links  of  the  chain. 

Except  for  special  reasons,  as  a  general  principle, 
the  limb  should  be  lifted  as  little  as  possible  from  the 
plane  upon  which  its  healthy  fellow  rests.  Indeed, 
the  writer  in  observance  of  this  principle  has  some- 
times depressed  the  underlying  portion  of  bed,  rather 
than  elevate  the  limb.  When  the  limb  is  much  ele- 
vated, the  lower  fragment  tends  by  gravity  to  over- 
ride the  upper  fragment  and  gives  rise  to  the  dis- 
agreeable necessity  of  using  some  sort  of  extension 
appai^atus  to  correct  the  difficulty,  with  a  consequent 
restriction  of  motion  of  the  lower  fragment.  By 
means  of  the  apparatus  the  resistance  to  motion  in 
horizontal  and  vertical  planes  and  to  rotation  upon 
the  long  axis  of  the  limb  has  been  lessened.  By  virtue 
of  the  elastic  suspension  from  a  single  point,  the  re- 
sistance to  elevation  of  the  limb  is  lessened,  which 
is  sometimes,  as  in  the  delirium  of  the  patient,  of 
material  advantage.  Given  the  wooden  upright 
bored  to  receive  the  iron  pipe,  and  the  wooden  bar 
shaped  to  form,  all  the  materials  can  be  assembled 
in  construction  by  the  surgeon's  own  hands,  at  least 
that  was  so  in  the  writer's  experience.  Frequently 
the  author  in  making  his  rounds  observed  patients 
who  were  able  to  walk  about,  sitting  in  their  chairs 
with  the  leg  in  splint  resting  in  the  suspension  ap- 
paratus described,  fastened  to  the  chair,  rather  than 


52       PRINCIPLES    OF   TREATMENT   OF   BROKEN    LIMBS 

resting  upon  a  pillow  in  an  opposite  chair.  To  in- 
quiry, the  answer  was  always  given  that  it  was  the 
more  comfortable  choice.  It  will  be  noted,  of  course, 
that  the  suspension  apparatus  for  the  patient  with 
fracture  of  both  thighs  was  an  adaptation  of  the  con- 
struction in  use  for  fractures  of  the  leg. 

In  the  preantiseptic  days  in  Bellevue  Hospital, 
when  that  institution  was  saturated  with  infection, 
it  was  customary  in  the  treatment  of  compound  frac- 
tures to  cut  fenestr^e  in  the  immovable  plaster-of- 
Paris  splint,  for  the  purpose  of  watching  and  treat- 
mg  the  wound.  It  generally  happened  that  there  was 
burrowing  of  pus,  and  the  opening  in  the  splint  had 
to  be  enlarged  to  increase  the  area  under  observation 
and  treatment.  This  led  the  author  by  rapid  steps  to 
finally  discard  altogether  the  encasing  and  conceal- 
ing splint,  obstructive  of  surgical  procedures,  and  to 
adopt  means  of  treatment  which  though  opposing 
feeble  resistance-  to  forces  tending  more  or  less  to 
displace  the  fragments,  gave  freest  access  for  obser- 
vation and  surgical  treatment.  The  splint  had  be- 
come restrictive  of  surgical  treatment  demanded  by 
the  functioning  of  the  injured  tissues. 

The  limb  was  so  circumstanced  that  while  some 
control  was  exerted  over  the  immobility  of  the  ad- 
justed fragments,  it  was  completely  open  to  inspec- 
tion and  palpation  and  treatment  of  the  wound  com- 
plications. All  absorbent  dressings  were  discarded. 
No  wound-dressings  were  used.  The  pus  drained 
away,  and  was  not  decomposed  by  being  held  in  con- 
tact with  the  warm  limb.  There  was  no  squeezing 
of  tissues  to  evacuate  sinuses,  indeed  in  tissues  that 


PRINCIPLES    OF   TREATMENT    OF   BROKEN    LIMBS      53 

were  not  handled  but  kept  in  absolute  physical  rest 
the  burrowing  of  pus  was  slight  or  did  not  occur. 
The  patient  was  spared  the  pain  of  the  usual  mode 
of  dressing.  The  dressing  was  only  the  substitution 
of  a  clean  for  a  soiled  support,  and  this  was  so  per- 
formed as  sometimes  not  to  awaken  the  patient  from 
sleep.  The  success  following  the  carrying  out  of 
these  principles  was  so  great,  especially  with  primary 
amputations,  that  the  wi'iter  was  slow  to  adopt  the 
antiseptic  measures  of  treatment  as  at  first  practiced. 
Later  experience  in  the  then  highly  septic  wards 
of  Bellevue  Hospital  convinced  the  author  that  anti- 
septic measures  of  treatment  could  fully  protect  pa- 
tients against  sepsis.  He  accordingly  discarded  the 
method  and  apparatus  which,  though  giving  the  ex- 
cellent results  in  his  hands  in  septic  surgical  practice, 
afforded  but  feeble  control  over  the  maintenance  in 
position  of  the  adjusted  bony  fragments.  Strict  anti- 
septic measures  having  reduced  the  chances  of  septic 
wound  complications  in  compound  fractures  to  the 
vanishing  point,  such  fractures  could  therefore  be 
placed  in  a  category  closely  allied  to  simple  frac- 
tures, and  a  consequent  greater  control  could  be 
exerted  over  the  maintenance  of  the  fragments  in  ad- 
justed position,  as  already  described  in  the  use  of  tin 
strips  in  conjunction  with  antiseptic  measures  of 
treatment. 


The  illustrative  instances  that  have  been  presented 
might  be  largely  increased  in  number  from  the 
author's  experience.  It  is  thought,  however,  that 
they  provide  ample  subject-matter  for  the  purposes 


54s       PRINCIPLES    OF   TREATMEXT    OF    BROKEN    LIMBS 

of  our  induction,  which  has  as  its  objective,  the  or- 
ganization of  the  facts  through  the  principles  which 
they  embody.  We  therefore  now  pass  from  a  con- 
sideration of  the  concrete  to  a  study  of  the  abstract. 

All  methods  of  treatment  of  fractures  of  the  long 
bones  to  insure  their  union,  however  diverse  in  char- 
acteristics, have  one  constant  feature  in  common, 
which  may  therefore  be  regarded  as  the  essential  fac- 
tor or  attribute.  This  attribute  is  maintained  immo- 
hility  of  the  fragments.  The  essential  nature  of  this 
attribute  is  further  shown  by  the  demonstrable  truth 
of  its  contradictory,  that  disturbance  of  the  continu- 
ous immobility  of  the  fragments  beyond  a  certain 
degree  will  prevent  their  union. 

It  has  been  pointed  out  that  no  extrinsic  apparel 
in  opposing  its  resistance  to  disturbing  forces  through 
the  soft  parts  can  completely  immobilize  the  frag- 
ments. While,  therefore,  maintained  absolute  immo- 
bility under  those  conditions  is  unattainable,  yet  a 
degree  of  immobility  practically  sufficient  to  insure 
union,  as  has  been  amply  demonstrated,  can  always 
be  achieved ;  this  attainable  degree  of  sufficient  immo- 
bility may,  therefore,  be  termed  practical  immobility, 
in  distinction  from  theoretical  or  absolute  immobility. 

Just  what  excursion  of  motion  between  the  frag- 
ments, disturbance  of  immobility,  may  take  place 
consistent  with  the  fragments  uniting,  is  not  easy  of 
determination;  it  probably  varies  with  individual  pa- 
tients. In  view  of  this,  it  is  incumbent  upon  the  sur- 
geon to  bestow  upon  his  patient  a  sufficient  factor  of 
safety  in  restricting  motion  between  the  fragments, 
to  insure  their  uniting. 


PEINCIPLES    OF   TREATMENT   OF   BROKEN    LIMBS      55 

The  maintained  practical  immobilization  of  the 
fragments,  in  the  realization  of  the  essential  attribute 
common  to  all  methods  of  treatment,  is  accomplished 
by  the  adjustment  of  mechanical  forces  to  resist  me- 
chanical forces  acting  to  disturb  their  immobility. 
The  essential  attribute  is  a  mechanical  one.  The 
measure  of  its  value  in  a  scheme  of  values  is  not  re- 
lated to  the  degree  of  attainable  immobility  per  se, 
said  attainable  immobility  in  turn  being  related  to  an 
ideal  standard  of  absolute  immobility  as  a  test  of  ex- 
cellence. The  measure  of  its  value  is  determined 
through  the  extension  of  that  factor,  in  the  relation 
of  the  varying  range  of  forces  maintaining  practical 
immobility,  to  the  incident  forces  tending  to  disturb 
it.  In  other  words  the  essential  attribute,  maintained 
practical  immobility,  is  treated  as  a  constant,  the 
range  of  forces  tending  to  disturb  the  immobility,  as 
the  functioning  variable. 

The  maintenance  of  practical  immobility  of  the 
fragments  by  the  adjustment  of  mechanical  forces  to 
oppose  a  varying  range  of  forces  tending  to  disturb 
that  immobility  is  proximately  measured  in  its  degree 
of  excellence  by  the  varying  range  of  coarse  motion 
of  the  organism,  the  test  of  excellence  being  shown 
in  the  degree  of  practical  realization  in  approach  to 
the  ideal  of  largest  range  of  coarse  motion.  In  brief, 
the  efficiency  of  the  essential  attribute,  sustained  prac- 
tical immobility,  being  granted,  the  measure  of  its 
value  is  the  varying  range  of  coarse  motion  of  the 
organism,  the  essential  attribute  being  preserved,  the 
highest  value  being  assigned  to  the  greatest  range  of 
coarse  motion  of  the  concerned  organism.     Changes 


56       PRINCIPLES    OF   TREATMENT   OF    BROKEN    LIMBS 

in  coarse  motion  in  their  turn  extend  their  effects  to 
all  the  various  fields  of  function. 

Xor  does  the  ideal,  it  may  be  noted,  propose  as  its 
limit  of  excellence  the  restoration  of  the  former  or 
so-called  normal  field  of  coarse  motion,  which,  in  re- 
sults, may  conceivably  be  even  surpassed. 

It  may  be  further  pointed  out  that  the  term  "re- 
sults" is  not  limited  in  its  application  to  a  certain 
period  of  treatment,  as,  for  example,  the  time  of 
union  of  the  fragments.  Such  is  an  arbitrary  limita- 
tion in  time  of  the  application  of  the  term.  The  esti- 
mation of  results  should  be  extended  to  include  any 
period  or  all  periods  of  treatment,  even  those  during 
which  union  is  taking  place. 

Results,  considered  as  immediate,  remote  and  mul- 
tiplied effects,  have  an  indefinite  extension  of  appli- 
cation, not  even  being  limited  bj^,  or  ceasing  with  the 
life  of  the  individual,  but  extending  their  influence 
to  the  effect  on  the  welfare  of  the  social  organism 
itself.  Indeed,  had  we  an  all-embracing  grasp,  all 
results,  like  all  actions,  from  the  smallest  to  the  great- 
est, should  be  determined  in  the  measurement  of  their 
value  by  this  final  of  all  tests.  A  proximate  test, 
however,  is  sufficient  for  our  inquiry.  In  determining 
the  relative  values  of  the  essential  attribute  embodied 
in  various  methods  of  treatment  in  its  extension,  the 
degree  of  excellence  is  in  the  proportionate  realiza- 
tion by  a  given  method  of  treatment  of  the  ideal  of 
highest  excellence,  as  sho'vvn  by  the  increase  in  motion 
of  the  affected  individual. 

The  means  by  which  the  essential  attribute  is  made 
operative,    in    other    words,    methods    of    treatment 


PRINCIPLES    OF   TREATMENT    OF   BROKEN    LIMBS      57 

considered  apart  from  the  essential  attribute  itself 
(which,  to  repeat,  is  a  mechanical  one),  and  consid- 
ered in  reference  to  their  inseparable  accidents  or 
characteristics,  may  be  generalized  under  two  heads: 

First,  in  their  local  influence,  affecting  functioning 
of  the  injured  limb. 

Second,  in  their  particular,  peculiar  effect  upon  the 
tissues ;  in  other  words,  in  their  therapeutic  influence. 
Both  heads  may  be  considered  under  the  effect  of 
function,  extending  the  connotation  of  the  term  func- 
tion beyond  its  ordinary,  arbitrary,  accepted  signifl- 
cation,  to  include  all  responses  of  the  concerned  tis- 
sues, whether  normal  or  abnormal,  to  the  distributions 
of  conditions  to  which  they  are  exposed. 

By  parity  of  consideration  with  that  of  the  essen- 
tial attribute,  it  is  evident  that  in  the  function  of 
variable  responses  to  varying  distributions  of  envir- 
oning conditions,  the  theoretical  maximum  of  excel- 
lence must  connote  the  largest  response  to  distribu- 
tions of  environing  conditions.  It  follows,  therefore, 
that  the  degree  of  excellence  is  necessarily  propor- 
tionate to  the  largest  response,  in  practical  realization 
of  approach  to  said  ideal  of  largest  response.  Under 
the  same  head  may  be  included  the  variable  results 
of  the  so-termed  therapeutic  influence.  To  repeat: 
The  results  following  from  the  effects  of  the  non- 
essential attributes  of  treatment  (the  inseparable  ac- 
cidents or  characteristics),  considered  apart  from 
those  due  to  the  realization  of  the  essential  attribute, 
are  to  be  measured  in  their  excellence  by  their  degree 
of  approach  to  the  ideal  of  highest  excellence,  in  terms 
of  function. 


58       PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS 

In  exhausting  the  subject-matter,  both  essential 
and  non-essential  attributes  of  treatment  inclusive 
may  be  generalized  in  their  results  under  the  head  of 
functional  responses  of  the  organism  to  the  distri- 
butions of  conditions  to  which  it  is  exposed.  The 
comparative  value  of  said  responses  in  their  imme- 
diate, remote,  and  cumulative  effects  are  measurable 
as  proportionate  to  the  largest  response,  in  approach 
to  the  theoretical  ideal  of  maximum  response. 

In  the  foregoing  reasoning,  which  has  been  briefly 
presented,  and  might  be  easily  elaborated,  and,  it  is 
trusted,  will  be  made  clear  by  illustrations,  the  author 
has  been  engaged  in  laying  the  foundation  of  imper- 
sonal proof  of  value  of  any  method  of  treatment,  to 
displace  the  bare  empirical  assertion  of  values  rest- 
ing on  personal  authority  or  consensus  of  opinion. 

The  voicings  of  personal  authority  may  contradict 
each  other,  or  when  made  by  the  same  individual  may 
vary  at  different  times.  The  weight  of  the  consensus 
of  opinion  may  sustain  one  conclusion  to-day*,  its 
contradictory  to-morrow. 

Impersonal  truth  alone  is  authoritative.  By  truth 
is  meant  that  peculiar  harmony  of  relations  revealed 
in  the  upbuilding  of  what  Prof.  Karl  Pearson  has 
happily  termed  "the  constructive  field  of  the  mind." 
Said  upbuilding  is  the  constructive  harmonizing  of 
continuous  principles,  abstractedly  derived  from  the 
complex,  fluid,  discontinuous,  ever-varying  phenom- 
ena of  the  external  world.  Such  organization  of  phe- 
nomena through  the  harmonizing  of  their  embodied 
principles  is,  as  the  author  conceives  it,  the  final  ob- 
jective of  all  scientific  endeavor. 


PRINCIPLES   OF  TREATMENT   OF  BROKEN   LIMBS      59 

In  the  region  of  empiricism,  the  social  organism 
guided  only  by  the  weight  of  changing  personal  au- 
thority or  the  consensus  of  opinion,  gropes  its  uncer- 
tain way ;  in  the  realm  of  scientific  exactitude,  guided 
by  immutable  principles,  it  confidently  pursues  a 
direct  and  certain  course,  and  by  proper  instrumen- 
talities at  its  command,  insures  the  betterment  of  its 
constituent  members. 

While  on  the  one  hand  the  surgeon  engages  in  his 
individual  work  for  the  welfare  of  his  patient,  on  the 
other  he  should,  through  principles,  instruct  and  equip 
the  social  organism  in  the  knowledge  of  the  preven- 
tion of  the  diseases  and  injuries  he  treats,  always, 
therefore,  in  acts  of  self-abnegation  being  engaged 
in  contracting  the  immediate  field  of  his  activity,  as 
it  were,  cutting  the  ground  from  beneath  his  own  feet. 

It  should  ever  be  borne  in  mind  when  the 
asserted  superiority  of  any  method  of  treatment 
is  challenged,  that  the  defendant,  to  prove  his  as- 
sertion, should,  avoiding  all  question  of  personal 
authority  or  consensus  of  opinion,  display  the  prem- 
ises and  the  reasoning  therefrom,  upon  which  his  con- 
clusion depends. 

So  far  as  relates  to  separable  accidents,  the  mere 
proof  that  they  are  separable  accidents  and  are 
avoidable,  is  sufficient  to  expose  their  entire  lack  of 
force  in  the  argument.  For  example,  the  writer  well 
remembers  an  occasion  when  an  immovable  splint  was 
removed  from  a  patient  with  a  simple  fracture  of  the 
shaft  of  the  femur.  The  fragments  of  bone  were 
united  with  no  shortening  or  other  deformity,  indeed 
with  a  perfect  result.    However,  the  point  of  a  pin 


60      PRINCIPLES   OF  TREATMENT   OF   BROKEN   LIMBS 

in  the  blanket  protective  covering  had  caused  a  very 
small  phlegmon  upon  the  abdomen.  This  had  caused 
so  little  discomfort  that  the  patient  had  made  no  com- 
plaint and  the  pustule  was  only  known  when  the 
splint  was  removed.  Yet,  a  distinguished  surgeon, 
an  authority  on  fractures,  who  was  present,  made 
careful  note  of  the  little  mishap  as  furnishing,  to  his 
mind,  an  argument  against  the  use  of  the  plaster-of- 
Paris  splint.  The  point  of  the  pin  might  have  been 
turned  outward,  or  the  pin  might  have  been  removed 
altogether.  It  was  by  no  means  a  necessary  element 
in  the  construction  of  the  splint.  The  irritation 
caused  by  it  was  perfectly  avoidable;  it  was  a  separ- 
able accident  and,  of  course,  had  no  logical  force  in 
an  argument  against  the  use  of  the  apparel. 

When  the  writer  first  entered  upon  his  service  as 
a  member  of  the  House  Staff  of  Bellevue  Hospital, 
the  following  incident  occurred  which  made  a  deep 
and  lasting  impression.  A  woman  with  simple  frac- 
ture of  both  bones  of  the  leg  in  the  middle  third  of 
the  leg  was  admitted  into  the  Hospital  soon  after  the 
occurrence  of  the  injury,  and  was  seen  by  the  Visiting 
Surgeon,  one  of  the  greatest  authorities  on  fractures. 
He  directed  that  the  fractured  leg  should  be  treated 
with  leather  side-splints,  which  was  at  once  done.  At 
his  visit  next  day,  the  patient  said  that  she  could  not 
sit  up  in  bed  without  feeling  the  bones  grate  upon 
each  other.  The  Visiting  Surgeon  criticised  the  ap- 
plication of  the  splints  and  reapplied  them  himself, 
and  also  directed  that  the  limb  be  suspended  by  loops 
of  bandage  dependent  from  a  simple  cradle  placed 
over  it.     The  next  day  the  patient  told  the  Visiting 


PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS      61 

Surgeon  the  same  story,  that  she  could  not  sit  up 
without  feeling  the  fragments  grate  upon  each  other. 
He  then  directed  the  House  Surgeon  to  apply  an 
immovable  plaster-of-Paris  splint.  The  next  day,  the 
Visiting  Surgeon  found  the  patient  dressed  and  sit- 
ting in  a  chair,  beside  the  bed,  the  fractured  limb  rest- 
ing upon  a  chair  opposite.  She  told  the  Visiting 
Surgeon  that  she  had  sat  up  in  bed,  was  dressed  with 
assistance,  and  had  otherwise  moved  about,  without 
feeling  any  grating  of  the  hones. 

In  strict  analysis,  what  had  happened  to  the  pa- 
tient? As  she  was  walking  across  the  street,  she 
was  knocked  down  by  a  passing  wagon  and  her  leg 
broken.  She  was  immediately  removed  by  ambulance 
to  the  Hospital.  By  the  fracture,  her  field  of  coarse 
motion,  specialized  in  locomotion,  had  suddenly  been 
contracted  to  a  very  small  one.  With  her  leg  in  a 
fracture-box  resting  upon  the  bed,  she  could  not  sit 
up  without  disturbing  the  immobility  of  the  frag- 
ments, thereby  destroying  the  essential  attribute  of 
treatment  necessary  to  their  uniting.  The  support 
of  the  limb,  practically  in  only  one  plane,  prevented 
any  but  the  smallest  range  of  coarse  motion.  En- 
cased in  movable  side-splints,  she  could  move  in  a 
very  small  range  without  disturbing  the  fragments. 
There  had  been  adapted  a  resistance  to  a  small  range 
of  disturbing  forces,  the  fragments  being  meanwhile 
held  immovable.  In  the  immovable  plaster-of-Paris 
splint,  resistance  was  adapted  to  overcome  a  consid- 
erable range  of  disturbing  forces,  that  otherwise 
would  destroy  the  requisite  immobility  of  the  relation 
of  the  fragments.     This  was  shown  by  the  greatlv 


62       PRINCIPLES   OF  TREATMENT   OF   BROKEN   LIMBS 

enlarged  field  of  coarse  motion  she  enjoyed,  without 
interfering  with  the  practical  immobility  of  the  frag- 
ments in  adjusted  relation,  and  their  consequent 
union. 

In  the  three  separate  distributions  of  conditions 
constituting  the  three  varieties  of  treatment,  the  es- 
sential attribute  of  maintained  practical  immobility 
of  the  fragments  had  been  preserved  with  three  dif- 
ferent results  as  marked  by  three  different  degrees 
of  extension  in  functioning  of  the  essential  factor  or 
attribute.  This  extension  was  expressed  by  three  dif- 
ferent degrees  of  coarse  motion,  the  essential  factor 
or  attribute  being  preserved,  as  shown: — 

First,  by  a  very  limited  range  of  coarse  motion. 

Second,  by  an  increase  in  the  range  of  coarse  mo- 
tion, and 

Third,  by  a  still  greater  range  of  coarse  motion. 

These  three  degrees  of  enlargement  of  coarse  mo- 
tion derived  their  value  in  excellence  measurable  by 
their  degree  of  approach  to  a  practical  realization  of 
the  ideal  of  greatest  range  of  coarse  motion.  Assign- 
ing highest  excellence  to  the  greatest  enlargement  of 
the  field  of  coarse  motion  in  practical  realization  of 
said  ideal,  then  the  second  distribution  of  conditions 
produced  a  result  of  higher  value  than  the  first  dis- 
tribution and  the  third  distribution  produced  a  result 
of  higher  value  than  the  other  two.  In  the  foregoing 
illustration  of  comparative  values,  consideration  has 
been  restricted  to  an  extension  of  the  essential  factor 
or  attribute,  as  a  functioning  variable. 

Limiting  our  consideration  to  the  essential  factor 
or  attribute,  the  term  plaster-of-Paris   splint  is   a 


PRINCIPLES   OF  TREATMENT   OF   BROKEN   LIMBS      63 

highly  ambiguous  one.  It  connotes  a  great  variety 
or  range  of  resistances,  as  expressed  in  extension  by 
degrees  of  coarse  motion  of  the  concerned  organism. 
For  example:  a  plaster-of-Paris  splint  may  be  so 
loosely  applied  that  it  affords  no  greater  resistance 
to  displacing  forces  than  the  simple  fracture-box  as 
shown  by  the  extremely  limited  range  of  coarse  mo- 
tion without  disturbance  of  the  fragments.  At  the 
other  extreme  it  may  be  so  efficiently  applied  that  it 
gives  a  great  resistance  to  otherwise  disturbing  forces, 
as  shown  by  a  great  range  of  coarse  motion  on  the 
part  of  the  concerned  organism,  without  disturbance 
of  the  practical  immobility  of  the  fragments.  It  may 
consequently  be  so  applied  as  to  develop  all  degrees 
of  resistance  between  the  extremes,  its  inseparable 
accidents  or  characteristics  remaining  the  same. 

Then  again,  the  enclosed  limb  may  so  diminish  in 
bulk  from  recession  of  swelling  as  to  greatly  change 
the  resistance  afforded  by  the  splint.  The  author 
has  seen  a  well-applied  splint  upon  a  limb  consider- 
ably swollen  allow  the  fragments  to  fall  out  of  ad- 
justed position  in  a  short  time  on  account  of  subsi- 
dence of  swelling,  and  the  splint  itself  afford  no  more 
resistance  to  disturbing  forces  than  a  roofed-in  frac- 
ture-box. 

In  any  argument  concerning  the  value  of  a  plaster- 
of-Paris  splint  applied  in  a  given  instance,  the  par- 
ticular resistance  to  incident  forces  which  it  connotes 
should  be  exactly  specified ;  better,  indeed,  the  specific 
connotation  should  be  used  rather  than  the  term  it- 
self, which  is  so  variable  in  its  connotation. 

In  compound  fractures,  or  simple  fractures  with 


64      PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS 

much  injury  to  the  soft  parts,  forbidding  that  degree 
of  compression  by  the  splint  to  afford  resistance  to  a 
large  range  of  incident  forces  tending  to  disturb  the 
practical  immobility  of  the  adjusted  fragments,  in 
other  words  limiting  the  extension  of  the  essential 
attribute  or  factor,  the  incident  forces  are  so  disposed 
by  suspension  apparatus  as  to  extend  the  functioning 
of  the  essential  factor,  thereby  increasing  the  range  of 
coarse  motion  of  the  concerned  organism. 

The  more  clearly  to  understand  the  use  of  suspen- 
sion apparatus  in  its  relation  to  the  extension  of  the 
essential  factor,  it  will  be  instructive  to  trace  in  the 
evolution  of  its  functioning  the  forms  of  apparatus 
that  have  been  described,  as  formerly  used  in  Bellevue 
Hospital. 

The  simplest  form  of  suspension  apparatus  is  that 
in  which  the  broken  leg  is  suspended  by  loops  of 
bandage  dependent  from  a  simple  cradle  placed  over 
the  limb.  This  apparatus  is  a  distribution  of  condi- 
tions modifying  the  incident  forces  otherwise  disturb- 
ing the  essential  attribute  (maintained  practical  im- 
mobility) in  such  a  manner  as  to  extend  the  relations 
of  the  attribute,  as  shown  by  the  enlargement  of  the 
field  of  coarse  motion  of  the  afflicted  organism,  mean- 
while preserving  the  essential  factor  in  its  efficient 
operation. 

Dr.  Van  Wagenen's  excellent  appliance  so  modi- 
fied the  distribution  of  disturbing  forces  as  to  extend 
the  functioning  of  the  essential  factor  or  attribute 
as  shown  by  the  greater  enlargement  of  the  field  of 
coarse  motion  of  the  concerned  organism,  the  opera- 
tion of  the  essential  factor  being  preserved. 


PRINCIPLES   OF   TREATMENT   OF  BROKEN    LIMBS      65 

The  apparatus  contrived  by  the  writer  still  further 
modifying  the  distribution  of  disturbing  forces,  in 
such  wise  as  to  extend  the  functioning  of  the  essential 
factor,  is  shown  by  a  larger  range  in  the  field  of 
coarse  motion  on  the  part  of  the  organism. 

In  recapitulation.  Appliance  No.  1  modified  the 
incident  forces  acting  upon  the  lower  fragment  prin- 
cipally in  a  single  plane  so  that  the  patient  could 
move  the  broken  limb  in  a  single  plane  without  the 
disturbance  of  maintained  practical  immobility  of  the 
fragments,  a  resulting  slight  enlargement  of  the  pa- 
tient's field  of  coarse  motion. 

Appliance  No.  2  (Van  Wagenen's)  modified  in- 
cident forces  operating  in  more  planes  and  especially 
those  forces  operating  upon  the  lower  fragment  to 
prevent  rotation  of  the  limb  on  its  longitudinal  axis, 
without  disturbance  of  the  fragments  in  adjusted  re- 
lation, a  resulting  decided  increase  in  the  patient's 
field  of  coarse  motion. 

Appliance  No.  3  (the  writer's)  modified  the  dis- 
tribution of  incident  forces  operating  in  more  planes 
and  upon  more  axes:  resulting  in  still  greater  in- 
crease in  the  patient's  field  of  coarse  motion  without 
disturbance  of  the  maintained  immobility  of  the  frag- 
ments. 

The  three  appliances  respectively,  were  distribu- 
tions of  environing  conditions  affecting  incident 
forces  tending  to  disturb  the  extension  of  the  essen- 
tial attribute  common  to  all  three  methods  of  treat- 
ment. They  were  extensions  of  the  functioning  of 
that  factor  as  shown  by  the  increasing  degrees  of  en- 
largement of  the  field  of  coarse  motion  of  the  pa- 


66       PRINCIPLES   OF   TREATMENT   OF    BROKEN    LIMBS 

tient,  the  action  of  the  essential  factor  being  always 
preserved. 

As  a  general  principle,  unless  special  reasons  con- 
tradict, the  suspended  linib  should  be  elevated  as  little 
as  possible  above  the  plane  upon  which  its  healthy 
fellow  rests.  A  notable  exception  is  suspension  in 
vertical  traction  of  a  simple  fracture  of  the  femur  in 
a  child,  which  strictly  analyzed  gives  the  greatest 
range  of  coarse  motion  of  the  individual,  the  essen- 
tial attribute  of  practical  mimobility  of  the  fragments 
being  preserved. 

The  elastic  suspension  acting  from  a  single  point 
was  advantageous  in  modifying  the  resistance  to  ele- 
vating the  limb,  which  was  of  importance  in  extend- 
ing the  range  of  coarse  motion  in  certain  critical 
conditions  of  the  patient,  like  delirium. 

Having  considered  diverse  categories  of  distribu- 
tions of  conditions  in  the  influence  upon  the  exten- 
sion of  the  essential  factor  or  attribute  as  expressed 
by  results  interpreted  in  terms  of  degrees  of  coarse 
motion  of  the  concerned  organism,  we  now  compare 
the  various  categories  of  distributions  of  conditions 
in  reference  to  their  inseparable  accidents  or  charac- 
teristics in  their  influence  upon  the  organism,  apart 
from  the  influence  upon  the  essential  factor.  This  is 
expressed  through  a  common  medium  of  proof  of 
their  value.  We  have  divided  this  consideration 
under  two  heads,  one  the  modification  of  the  con- 
cerned organism  expressed  in  terms  of  function,  and 
two,  the  special  or  therapeutic  influence  of  such 
distributions  of  conditions  as  exerted  by  extrinsic 
apparel. 


PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS      67 

One:  It  is  to  be  understood  in  our  consideration 
that  the  signification  of  function  is  not  arbitrarily 
limited  to  modification  of  the  responses  usually  ex- 
pressed by  normal  or  healthy  tissue,  but  is  extended 
to  include  all  responses  of  the  concerned  tissues.  This 
comparison  is  perhaps  best  made  by  a  study  of  the 
categories  of  distributions  of  conditions  themselves, 
taking  for  our  study  as  illustrative  examples  three 
different  methods  of  treatment  of  a  given  fracture 
of  the  leg,  first,  in  a  fracture-box;  second,  by  mov- 
able side-splints,  and  third,  by  immovable  plaster- 
of-Paris  splint. 

So  far  as  relates  to  ordinary  phases  of  functioning, 
the  first  or  simple  support  in  the  fracture-box  (con- 
sidered apart  from  the  essential  factor)  imposes  the 
least  limitation  upon  ordinary  function.  Such  dis- 
tribution also  imposes  the  least  restraint  upon  surgi- 
cal relations  of  the  injury.  In  the  latter  respect  the 
injury  is  open  to  inspection,  palpation  and  extended 
surgical  treatment. 

In  the  second  category,  that  of  movable  side-splints, 
there  is  greater  restraint  upon  what  is  termed  normal 
functioning,  and  there  is  also  greater  restraint  upon 
the  functioning  of  the  limb  in  reference  to  surgical 
relations.  The  tissues  are  not  so  readily  open  to  in- 
spection, palpation,  or  surgical  treatment. 

In  the  third  category,  that  of  the  immovable  plas- 
ter-of-Paris  splint,  there  is  a  still  greater  restriction 
than  in  the  other  two  categories,  upon  the  normal 
functioning  of  the  limb.  The  tissues  are  withdrawn 
from  inspection,  palpation,  and  are  not  open  to  a 
range  of  surgical  procedures. 


68       PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS 

In  recapitulation,  the  first  category  of  conditions 
imposes  the  least  restraint  upon,  or  limitation  to 
functioning  responses,  including  surgical  relations. 
The  second  imposes  a  greater  limitation  of  responses, 
and  the  third  and  greatest  of  all  limitations  of  re- 
sponses, limiting  the  surgical  relations  to  a  near  ap- 
proach to  the  vanishing  point. 

In  therapeutic  influence,  which  is  really  a  phase  of 
functioning,  the  first  category  of  conditions  imposes 
no  special  therapeutic  influence  upon  the  tissues  be- 
yond physical  rest;  the  second  category  imposes  the 
deleterious  influence  of  more  or  less  confinement  and 
withdrawal  from  the  light;  the  third  category  accen- 
tuates the  effects  of  confinement  and  absence  from 
light  and  air,  to  which  may  possibly  be  added  a  special 
influence  from  the  material  of  the  permanent  apparel 
itself.  Broadly  expressed,  the  therapeutic  influence 
of  the  environing  distribution  of  conditions  in  the  third 
instance  is  at  the  maximum ;  in  the  second  category  it 
is  in  moderate  degree;  and  in  the  first  category  it  is 
near  the  vanishing  point. 

The  therapeutic  influence  of  the  plaster-of-Paris 
splint  is  of  such  great  importance  as  to  demand  ex- 
tended consideration.  It  is  not  to  be  overlooked  that 
in  the  early  stages  of  its  application  the  plaster-of- 
Paris  apparel  exerts  a  beneficent  influence  upon  the 
included  tissues  mainly  by  inducing  rest  and  quieting 
muscular  action.  The  injurious  effect  of  the  splint  is 
cumulative,  increasing  with  the  duration  of  its  appli- 
cation. Great  changes  are  induced  in  the  skin  as 
shown  by  its  anaemia  and  readiness  to  become  oedema- 
tous.     Nor  is  the  deleterious  influence  of  the  splint 


PRINCIPLES    OF   TREATMENT   OF   BROKEN    LIMBS      69 

limited  to  the  skin,  but  extends  to  all  soft  tissues  and 
even  to  the  bones  themselves.  The  changes  in  the 
soft  parts  are  not  only  evident  but  also  invisible,  and 
are  strikingly  illustrated  by  their  behaviour  under 
infection. 

In  preantiseptic  days  when  Bellevue  Hospital  was 
saturated  with  infection,  great  care  was  exercised  in 
the  removal  of  splints  lest  the  skin  be  scratched  and 
infected  with  erysipelas.  Nevertheless,  erysipela- 
tous infection  frequently  occurred.  The  destruction 
wrought  by  such  infection  upon  the  tissues  that  had 
been  covered  by  the  splint  was  wide-spread  and  in 
some  instances  accompanied  by  unusually  large  and 
deep  sloughs  of  subcutaneous  tissues.  In  some  in- 
stances the  erysipelatous  inflammation  would  rapidly 
sweep  over  the  limb  affecting  the  portion  formerly 
encased  in  the  splint,  and  then  stop  abruptly  in  a 
sharp  circular  line,  bounding  the  upper  limit  of  the 
splint. 

The  deleterious  therapeutic  influence  of  the  splint 
was  in  addition  also  otherwise  shown  in  striking  man- 
ner as  affecting  the  union  of  the  bony  fragments.  In 
one  illustrative  instance,  a  patient  with  a  compound 
fracture  of  both  bones  of  the  leg,  had  been  treated 
in  a  plaster-of-Paris  splint  without  suspension  of  the 
limb,  for  more  than  six  weeks.  Suppurating  sinuses 
connecting  with  the  wound  had  formed,  as  was  fre- 
quently the  case  in  such  injuries.  The  wound  was 
not  yet  healed  when  the  splint  was  removed.  There 
was  no  union  of  the  bones  whatever,  and  the  limb 
taken  from  the  splint  was  placed  in  a  fracture-box. 
The  exposed  limb,   enjoying  its  larger  functional 


70       PRINCIPLES    OF   TREATMENT    OF    BROKEN    LIMBS 

range,  was  then  frequently  sponged,  and  stroked  with 
the  hand,  the  immobility  of  the  fragments  meanwhile 
not  being  disturbed.  To  the  astonishment  of  the 
House  Staff,  in  four  days  the  leg  began  to  stiffen  and 
heaHng  progressed  rapidly  to  a  complete  union  of 
the  fragments. 

A  patient  with  a  simple  fracture  of  both  bones  of 
the  leg  at  the  middle  of  the  leg,  was  in  the  middle 
period  of  pregnancy.  After  the  limb  had  been  en- 
cased in  a  well-fitting  plaster-of-Paris  splint  for  six 
weeks  she  came  under  the  writer's  care.  There  was 
no  union  of  the  fracture  whatever.  There  was  free 
angular  motion  at  the  site  of  fracture.  The  limb  was 
forcibly  douched  'with  hot  and  cold  water  alternately, 
always  leaving  off  with  the  cold  douche.  The  limb 
was  gently  massaged  three  times  daily,  and  the  pa- 
tient was  encouraged  to  exercise  the  muscles  of  the 
affected  limb  under  the  stimulus  of  the  will,  the  frag- 
ments during  all  procedures  being  held  immobile. 
The  splint,  which  had  been  cut  down  in  the  anterior 
median  line  was  used  as  a  movable  apparel,  and  w^orn 
only  when  the  limb  was  exposed  to  injury,  and  con- 
sequently was  very  seldom  upon  the  limb  during  the 
day-time.  In  a  very  few  days  the  fragments  began 
to  unite;  the  bones  stiffened  and  union  progressed 
uninterruptedly  to  solidity. 

In  other  patients,  where  there  had  been  long  de- 
layed union  from  prolonged  confinement  in  immov- 
able plaster-of-Paris  splints,  with  apparently  hope- 
less prospect  of  union,  indeed,  in  two  cases  that  had 
been  condemned  to  operation,  the  same  practice  of 
revivification  narrated  above    (persistent  invitations 


PRINCIPLES   OF  TREATMENT   OF   BROKEN   LIMBS      71 

to  increase  of  function)  was  completely  successful  in 
steadily  effecting  complete  and  solid  union  of  the 
fragments. 

The  measures  were  strikingly  successful  in  one  re- 
markable case  in  private  practice,  of  delayed  union 
of  fracture  of  the  humerus  of  several  weeks'  duration 
which  seemed  hopeless  of  union  and  in  which  the  open 
operation  upon  the  fragment  had  been  advised  as  the 
only  presumed  remaining  resource. 

In  the  author's  own  practice,  which  was  very  ex- 
tensive, he  rarely  had  an  instance  of  delayed  union 
and,  according  to  his  recollection,  never  an  instance 
of  non-union  in  any  variety  of  fracture. 

In  brief,  the  plaster-of-Paris  splint,  in  its  mechani- 
cal, essential  attribute  embodies  the  greatest  mechani- 
cal resistance  to  forces  tending  to  disturb  the  con- 
tinuous practical  immobility  of  the  fragments  in  their 
adjusted  relation,  as  shown  by  the  extension  of  that 
attribute  as  a  functioning  variable,  its  superior  ex- 
cellence being  shown  by  the  large  range  of  coarse 
motion  of  the  organism,  the  practical  immobility  of 
the  adjusted  fragments  being  maintained.  On  the 
other  hand,  in  its  non-essential,  constant  attribute, 
that  is,  in  its  inseparable  accidents  or  characteristics, 
so  far  as  its  therapeutic  influence  is  concerned,  it  is 
the  most  deleterious  of  all  extrinsic  appliances  that 
have  been  reviewed.  It  is  very  restrictive  of  function 
of  the  included  tissue,  giving  to  the  term  function  its 
broadest  signification. 

This  restriction  for  a  limited  time  of  early  treat- 
ment is  beneficial  by  quieting  the  muscles  and  thereby 
indirectly  assisting  in  the  maintenance  of  immobility 


72       PEIXCIPLES    OF    TREATMENT    OF    BROKEN    LIMBS 

of  the  fragments.  The  induced  oedema  also  assists  in 
the  tight  packing  of  the  splint  thereby  promoting  its 
mechanical  efficiency.  In  its  continued  application, 
however,  by  its  restriction  of  the  surgical  relations  of 
the  limb  (its  surgical  functioning)  by  preventing  in- 
spection and  palpation,  it  greatly  diminishes  the  range 
of  choice  of  beneficial  surgical  measures  otherwise 
included  in  the  categories  of  conditions  constituting 
the  treatment  of  the  injury.  The  distinctly  bad 
therapeutic  influence  of  the  splint  upon  all  included 
tissues,  said  injurious  influence  being  cumulative  and 
proportioned  to  the  duration  of  the  application  of  the 
splint  is  in  strong  contrast  with  the  distinctly  bene- 
ficial influence  of  the  contradictory  in  categories  of 
conditions,  which  enlarge  the  functioning  of  the 
tissues,  using  the  term  functioning  in  its  widest 
signification. 

It  follows  therefore  that  in  the  distributions  of  con- 
ditions through  the  use  of  extrinsic  apparel,  to  evoke 
the  largest  responses  from  the  organism  the  plaster- 
of-Paris  splint  should  be  applied  during  the  earlier 
stages  of  treatment  when  the  adjusted  fragments 
may  be  the  more  easily  distributed  in  their  immobility 
and  when  the  tissues  are  healthy.  In  the  latter  stages 
of  treatment  when  the  fragments  may  be  the  more 
easily  held  immobile,  the  plaster-of-Paris  splint 
should  be  discarded  and  for  it  should  be  substituted 
some  form  of  movable  splint  which,  while  continuing 
equally  well  the  operation  of  the  essential  factor  of 
maintained  practical  immobility  at  the  same  time  al- 
lows a  larger  response  to  be  evoked  from  the  func- 
tioning tissues. 

In  the  author's  treatment  of  compound  fractures 


PRINCIPLES    OF   TEEATMENT   OF   BROKEN    LIMBS      73 

in  preantiseptic  days  in  an  infected  hospital,  the 
plaster-of-Paris  splint  was  gradually  discarded  by 
him.  Instead  of  the  splint  there  were  substituted 
appliances  which  permitted  an  enlarged  range  of  sur- 
gical treatment.  To  reach  and  treat  complications 
of  the  septic  wound,  the  window  in  the  splint  was  at 
first  enlarged,  then  further  enlarged,  and  finally  the 
obstructing  envelope  of  the  splint  was  discarded  alto- 
gether. To  give  extension  to  the  essential  factor 
under  such  circumstances,  special  appliances  were 
devised,  which  in  the  author's  hands  yielded  satis- 
factory results.  Some  control  was  exerted  over  the 
inunobility  of  adjusted  fragments  as  shown  by  some, 
though  limited,  range  of  coarse  motion.  The  inju- 
rious therapeutic  influence  of  the  splint  was  elimi- 
nated and  an  extended  surgical  functioning  range  of 
the  tissues  was  secured. 

Some  of  the  appliances  used  were  somewhat  com- 
plex in  construction  but  quite  simple  and  effective  in 
action.  In  their  turn,  efficient  antiseptic  measures 
totally  changed  the  distribution  of  conditions  in 
wound  treatment,  and  allowed  the  substitution  for 
the  complicated  treatment  of  compound  fractures  of 
a  category  of  conditions  closely  allied  to  that  used  in 
the  treatment  of  simple  fractures.  This  of  course 
resulted  in  its  turn  in  a  further  extension  of  the  opera- 
tion of  the  essential  factor  as  marked  by  an  increase 
in  the  range  of  coarse  motion,  the  maintained  practi- 
cal immobility  of  the  adjusted  fragments  being  un- 
disturbed by  incident  mechanical  forces ;  at  the  same 
time  the  influence  of  the  wound  as  a  complicating 
element  was  reduced  to  the  vanishing  point. 


74       PRINCIPLES    OF   TREATMENT    OF   BROKEN    LIMBS 

In  the  instance  of  simple  fracture  of  both  femora 
at  the  middle  of  their  shafts,  after  the  immovable 
splints  had  been  applied,  the  patient  was  anchored 
in  one  position  in  bed  from  which  he  could  not  move 
except  when  helped.  He  very  soon  became  dis- 
pirited and  lost  strength.  The  suspension  appliance 
shown  in  the  photograph  was  at  once  devised.  By  its 
means  the  patient's  range  of  coarse  motion  was  im- 
mediately enlarged,  with  a  consequent  improvement 
in  morale  and  gain  in  strength.  His  increase  in 
weight  kept  the  splint  a  snug  fit  and  consequently 
an  efficient  mechanical  resistance  to  incident  mechani- 
cal forces.  The  splint  was  not  once  changed  till  it 
was  finally  removed,  when  the  fractures  were  found 
united  without  deformity  and  of  equal  length.  Such 
a  result  is  indeed  even  apparent  from  an  inspection 
of  the  photograph  showing  the  limbs  still  encased  in 
the  splints. 

To  generalize : — ^We  have  found  that  the  measure- 
ment of  the  essential  attribute  (maintained  immo- 
bility), under  extension  from  a  zero  toward  a  maxi- 
mum, comprehends  variation  in  coarse  motion  of  the 
concerned  organism.  This  variation  extends  from  a 
lessened  degree  caused  by  injury,  through  a  range  of 
increased  motion  toward  a  maximum,  which  maxi- 
mum is  a  proximate  measuring  test  of  the  realization 
of  the  criterion  of  excellence.  These  variations  in 
coarse  motion,  though  classified  as  variations  in  spe- 
cial functionings  of  the  organism,  may  be  generalized 
as  responses  of  given  states  of  the  organism  to  given 
distributions  of  conditions  constituting  the  phases  of 
treatment  of  the  injuries.    Likewise,  the  variations  of 


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PRINCIPLES   OF  TREATMENT   OF  BROKEN   LIMBS      75 

the  characteristics  of  treatment  (the  inseparable  ac- 
cidents) extend  through  a  range  from  a  zero  to  a 
largest  functioning,  which  functioning,  however  spe- 
cialized in  classfication,  may  be  constituted  and  made 
measurable  as  responses  of  the  given  states  of  the 
organism  to  given  distributions  of  conditions,  all  be- 
ing in  relation  to,  and  measuraJble  by,  the  criterion  of 
highest  excellence  constituted  by  the  largest  number 
of  responses. 

It  is  thus  found  that  both  the  essential  attribute, 
and  the  inseparable  accidents  (characteristics)  of  all 
methods  of  treatment  (exhausting  the  subject-matter 
under  study)  may  be  generalized  under  the  common 
head  of  responses  of  the  concerned  organism  to  the 
distributions  of  conditions  to  which  it  is  exposed  by 
the  proceedings  of  surgical  art. 

The  measure  of  quality  is  necessarily  quantitative 
and  in  the  last  analysis  is  resolvable  into  and  expres- 
sible in  terms  of  number. 

It  is  gratifying  to  find  that  the  conclusion,  inde- 
pendently reached  through  our  induction,  harmonizes 
with  the  Spencerian  definition  of  Life. 

Spencer,  in  his  "First  Principles,"  says:  "Divest- 
ing the  conception  of  all  superfluities  and  reducing 
it  to  its  most  abstract  shape,  we  see  that  Life  is  de- 
finable as  the  continuous  adjustment  of  internal  rela- 
tions to  external  relations.  And  when  we  so  define 
it  we  discover  that  the  physical  and  the  psychical  life 
are  equally  comprehended  by  the  definition." 

Such  continuous  adjustments  are  expressed  in  re- 
sponses of  the  organism  and  may  be  quantitatively 
measured  in  terms  of  number.    The  individual  life 


76       PRINCIPLES   OF   TREATMENT   OF  BROKEN   LIMBS 

as  a  variable,  measurable  in  terms  of  number,  ob- 
viously extends  in  variation  from  a  zero,  or  vanishing 
point,  to  a  maximum  number  of  responses. 

The  categories  of  distributions  of  conditions  con- 
stituting the  treatment  of  injuries  evoke  a  variable 
number  of  responses,  which  variations  in  number  ex- 
tend from  a  zero  to  a  maximum.  In  our  ideal  scheme 
of  values  the  criterion  of  highest  excellence  is  con- 
stituted by  the  maximum  number  of  responses. 

Practically,  the  surgeon  is  always  engaged  in 
determining  by  observation,  and  defining  the  cate- 
gories of  conditions  embraced  in  varying  states  of  the 
organism.  His  treatment  consists  in  supplying  to  the 
defined  categories  of  conditions  embraced  in  given 
states  of  injury  given  categories  of  distributions  of 
conditions.  The  categories  of  responses  evoked  from 
the  organism,  constituting  the  results  of  treatment, 
are  measurable  by  the  connoted  number  of  responses. 
Their  value  is  estimated  in  relation  to  a  maximum 
number  of  responses,  constituting  the  practical  reali- 
zation of  approach  to  the  maximum  number  of  re- 
sponses constituting  the  ideal  of  supreme  excellence. 
It  follows  therefore  in  comparison  of  the  value  of 
methods  judged  by  their  results,  that  that  method  of 
treatment  is  better  and  to  be  preferred  over  another, 
which  in  its  result  evokes  the  larger  number  of  re- 
sponses measured  in  the  presence  of  the  criterion  of 
highest  value,  the  maximum  number  of  responses. 

The  results  of  treatment  in  connoted  responses* 
called  forth  from  the  concerned  organism  by  the  cate- 
gory of  distribution  of  conditions  to  which  it  is  ex- 
posed, in  their  effects  are  immediate,  cumulative  and 


PRINCIPLES    OF   TREATMENT    OF    BROKEN    LIMBS      77 

remote,  extending  their  influence  to  the  social  or- 
ganism. 

It  will  be  observed  that  the  criterion  of  value 
though  most  general  in  expression  includes  classified 
functions  of  the  organism,  modes  of  relation. 

In  the  complex  and  variable  subject-matter  em- 
braced in  the  province  of  surgery,  the  formation  and 
definition  of  distinct  groups  or  categories  is  an  im- 
portant task. 

These  categories  embrace  states  of  the  organism, 
distributions  of  conditions  constituting  surgical  treat- 
ment of  said  states,  and  categories  of  responses  con- 
stituting the  given  results  of  treatment. 

Refinements  of  observation,  changes  in  the  or- 
ganism itself,  the  invention  of  new  distributions  of 
conditions  in  treatment,  lead  to  the  creation  of  new 
categories  and  their  consequent  definition. 

The  multiplication  of  instances  in  categories  al- 
ready constituted  and  defined,  as  an  end  in  itself,  is, 
scientifically  viewed,  an  unnecessary  loading  of  the 
record  in  confirmation  of  that  which  has  already  been 
established. 

The  writer  knew  a  surgeon  who  died  unhappy  be- 
cause he  had  performed  a  certain  operation  only 
ninety-nine  times,  failing  to  obtain  and  operate  his 
hundredth  patient.  And  yet,  all  his  operations  added 
nothing  new  to  categories  already  known  and  defined, 
extended  no  new  embodied  principle  and  after  all, 
only,  as  is  too  often  the  case,  burdened  the  record  to 
no  commensurate  useful  end.  Indeed,  the  very 
operation  which  he  performed  with  so  much  skill  and 
pride  was  very  properly  superseded  before  his  death 
by    another    operation    attaining   the    same    object 


78       PRINCIPLES   OF   TREATMENT    OF    BROKEN    LIMBS 

equally  well,  and  with  the  advantage  of  expressing 
much  greater  scope. 

To  sum  up:  A  given  fracture  is  a  given  definable 
category  of  conditions  of  the  state  of  the  injured  or- 
ganism. A  given  treatment  of  the  fracture  is  a  given 
definable  category  of  distribution  of  conditions  to 
which  the  given  injury  is  exposed.  The  result  of 
treatment  is  a  given  definable  category  of  responses 
evoked  from  the  injured  organism  consequent  upon 
its  exposure  to  the  given  category  of  distribution  of 
conditions  constituting  the  treatment.  The  criterion 
or  measure  of  value  of  the  results  of  treatment  is  the 
largest  number  of  evoked  responses,  in  practical  reali- 
zation of  approach  to  the  conceived  ideal  of  maximum 
number  of  responses. 

There  may  be  difficulty  in  determining  and  defin- 
ing the  given  categories  but  the  method  of  determi- 
ning values  remains  alticays  the  same  and  immutable, 
unaffected  by,  and  independent  of,  the  dicta  of  per- 
sonal authorities  or  the  consensus  of  opinion. 

Reduced  to  syllogistic  form,  that  method  of  treat- 
ment when  compared  with  another  is  better  and  to  be 
preferred,  that  evokes  the  larger  number  of  connoted 
responses  from  the  category  of  distribution  of  con- 
ditions to  which  the  injury  is  exposed,  in  practical 
realization  of  approach  to  the  ideal  of  supreme  ex- 
cellence, which  is  that  of  the  largest  number  of  re- 
sponses. A  certain  method  of  treatment  in  its  results 
shows  a  larger  number  of  responses  in  practical  reali- 
zation of  approach  to  the  ideal  of  maximum  number 
of  responses  when  compared  with  others,  and  is  there- 
fore the  better  method  and  should,  in  obedience  to 
ethical  requirements,  be  preferably  adopted. 


SEPTIC  SATURATION  OF  BELLEVUE 

HOSPITAL  IN  THE  SEVENTIES. 

BATTLE    AGAINST    SEPSIS 

The  saturation  of  Bellevue  Hospital,  in  the  seven- 
ties, with  erysipelas  infection  is  well  illustrated  by 
the  following  example:  On  one  occasion  in  entering 
upon  his  term  of  service,  the  writer  found  in  his  ward 
a  patient  suffering  from  a  discharging  sinus  of  the 
brain  caused  by  a  pistol-shot  wound  inflicted  six 
weeks  before  (see  Plate  XX,  Fig.  A).  The  sinus 
having  definite  walls  was  easily  probed  and  the  ball 
touched  near  the  centre  of  the  brain.  Small  hair-pin 
like  retractors  were  made  of  wire.  The  brain  was 
slightly  incised  and  the  imbedded  ball  was  plainly 
seen  in  its  position.  It  was  seized  with  proper  for- 
ceps, but  was  felt  to  resist  traction  upon  it  very  much 
as  a  button  sewn  upon  a  coat.  The  ball  was  partly 
encysted.  It  was  wiped  clean  and  a  small  flake  of 
lead  was  picked  from  it  with  forceps.  Recognizing 
that  an  attempt  to  remove  the  ball  was  fraught  with 
great  danger  and  being  under  the  obligation  not  to 
perform  any  dangerous  operation  upon  the  patient, 
manipulation  was  restricted  to  wiping  the  sinus  clean 
with  the  object  of  disinfecting  and  healing  it.  The 
sinus  healed  kindly  till  only  a  spot  of  granulations 
about  the  size  of  the  thumb-nail  remained. 

79 


80       PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS 

At  a  visit  at  this  time  to  inspect  the  wound,  the 
corner  of  the  covering  antiseptic  dressing  was  lifted 
just  enough  to  give  a  view  of  the  wound.  The  gauze 
stuck  to  the  granulations  and  in  lifting  it  a  bleeding 
of  two  or  three  drops  was  caused.  Just  at  that  mo- 
ment a  near-by  door  leading  into  the  corridor  and 
stairway  was  opened  permitting  a  strong  inrush  of 
cold  air.  The  door  was  instantly  shut.  This  hap- 
pened at  the  very  instant  the  dressing  was  lifted  and 
sight  caught  of  the  wound.  At  the  same  moment  the 
gauze  which  had  not  been  removed  clear  from  the 
head,  but  turned  slightly  back,  was  at  once  turned 
down  and  bandaged  again  in  position.  The  whole 
incident  occupied  but  a  few  seconds.  The  patient 
was  shortly  afterward  seized  with  a  chill  and  affected 
with  erysipelas  spreading  from  the  wound.  His  head 
swelled  enormously,  closing  his  eyes,  etc.  Fortu- 
nately the  erysipelas  ran  a  favorable  course  without 
suppuration.  The  patient  recovered  and  was  dis- 
charged cured. 

It  was  clear  that  the  broken  small  spot  of  granula- 
tions was  infected  during  the  brief  exposure  at  the 
time  the  blast  of  air  came  in  through  the  opened  door. 
The  writer  hav'ing  no  case  of  erysipelas  in  his  wards 
was  interested  in  tracing  the  source  of  infection.  He 
found  the  ward  immediately  below  the  one  occupied 
by  his  patient  was  being  dismantled  for  fumigation, 
on  account  of  an  outbreak  of  erysipelas  which  had 
affected  three  or  four  patients,  spreading  from  bed 
to  bed,  adjoining.  It  was  perfectly  clear,  therefore, 
that  the  infection  originating  in  the  ward  one  flight 
of  stairs  below,  had  passed  into  the  corridor,  lurked 


PRINCIPLES    OF   TREATMENT   OF   BROKEN    LIMBS      81 

upon  the  stairs,  and  entered  the  writer's  ward  upon 
the  blast  of  air  when  the  door  was  opened. 

The  septic  condition  of  the  wards  was  so  generally 
known  that  it  had  become  a  matter  of  public  noto- 
riety. Patients  dreaded  to  be  carried  into  Bellevue 
Hospital  and  with  good  reason.  Their  outlook  for 
recovery  from  serious  wounds  would  have  been  far 
better  had  they  been  operated  upon  in  the  open  street 
where  they  had  been  injured,  and  afterward  cared  for 
there  by  the  charity  of  the  passers-by.  The  Hospital, 
although  provided  with  a  staff  of  brilliant  surgeons, 
was  a  centre  of  danger.  It  was  the  only  large  hos- 
pital that  served  the  needs  of  a  great  and  growing 
city  and  was  crowded  with  patients  suffering  from 
open  wounds.  The  writer  never  saw  a  healthy  open 
wound  for  the  year  and  a  half  while  he  was  interne 
of  Bellevue  Hospital.  The  simplest  as  well  as  the 
most  serious  wounds  alike  became  infected,  and  pa- 
tients in  greatest  proportion  of  instances  died  from 
septicemia  and  pyaemia.  The  complications  due  to 
sepsis  were  a  great  discouragement  to  operative  pro- 
cedures and  as  a  consequence  attention  and  skill  were 
concentrated  and  lavished  upon  bloodless  operations. 
The  peculiarities  of  the  practice  of  septic  surgery 
required  great  skill  and  trained  judgment  and  stress 
was  very  properly  laid  upon  the  education  of  the 
hands,  or  as  expressed  in  established  phrase,  the 
''t actus  eruditus." 

The  great  prevalence  of  sepsis  early  drew  the 
writer's  attention  to  the  invention  of  preventive  meas- 
ures against  the  dread  disease.  Thinking  that  per- 
haps the  poor  nourishment  provided  by  the  Hospital 


82       PRINCIPLES   OF  TREATMENT    OF   BROKEN    LIMBS 

was  a  factor  of  some  importance,  he  organized  a  pri- 
vate source  of  food  supply  for  certain  patients  suffer- 
ing from  the  most  serious  open  wounds  and  primary 
amputations.  The  better  feeding  had  no  perceptible 
influence  in  diminishing  the  occurrence  of  septicaemia. 
He  next  directed  his  attention  to  the  overcrowded 
condition  of  the  wards  with  open  wounds.  Acting 
upon  this  line  of  thought,  he  cleared  one  of  the  larg- 
est wards  of  all  patients  having  any  open  wound  what- 
soever. In  such  a  ward,  he  placed  a  patient  with  a 
primary  amputation,  the  operation,  of  course,  having 
been  most  skilfully  performed  by  an  exceptionally 
experienced  surgeon.  This  patient  was  unremittingly 
attended  night  and  day  by  the  best  nurses,  and  pro- 
vided with  the  best  nourishment.  In  spite  of  all,  he 
developed  septicemia  and  followed  the  fatal  course 
of  his  predecessors. 

About  this  time,  the  writer  was  selected  to  take 
charge  of  and  reorganize  "the  Park  Reception  Hos- 
pital." This  was  the  first  reception  hospital  that 
was  established  in  the  city.  It  cared  for  all  emer- 
gency patients  in  the  lower  part  of  the  City,  below 
Canal  Street,  and  had  been  in  operation  between  two 
and  three  years.  Although  a  great  many  patients 
were  transferred  from  the  Reception  Hospital  to 
Bellevue  Hospital,  yet  its  wards  were  crowded  with 
patients  suffering  from  serious  injuries. 

The  large  number  of  deaths  from  septicaemia  in 
Bellevue  Hospital  was  of  such  common  knowledge 
that  the  newspapers  mooted  the  advisability  of  tear- 
ing down  that  great  Central  Hospital  and  building 


PRINCIPLES   OF  TREATMENT   OF   BROKEN   LIMBS      83 

in  its  stead,  at  different  places  about  the  City,  numer- 
ous small  hospitals. 

A  committee  of  the  Medical  Board  of  Bellevue 
Hospital  investigating  the  matter  found  that  a 
greater  proportion  of  patients  died  from  septicaemia 
and  pyaemia  in  the  small  Reception  Hospital  than  in 
Bellevue  Hospital.  Patients  were  dying  in  "The 
Park  Reception  Hospital"  from  those  complications 
when  the  writer  took  charge.  Experience  in  Bellevue 
Hospital  had  taught  the  writer  that  skilful  perform- 
ance of  operations,  combined  with  nourishment  with 
the  best  food,  the  most  careful  nursing,  together  with 
reducing  the  number  of  open  wounds  in  a  ward  to  a 
single  wound,  all,  had  no  perceptible  influence  in  pre- 
venting the  disease.  One  factor  remained  and  that 
was  the  influence  of  the  environing  walls  of  the  hospi- 
tal wards  themselves.  In  Bellevue  Hospital  the  floors 
had  been  washed  and  the  bedding  changed  frequently 
enough,  but  the  walls  of  the  wards  had  not  been 
washed  within  recollection.  The  writer  reasoned  that 
the  infected  walls  constituted  the  efficient  causative 
factor  of  which  he  was  in  search.  Accordingly,  in 
assuming  control  of  the  Park  Hospital  in  which,  as 
stated,  patients  at  the  time  were  dying  from  infec- 
tion, he  directed  his  attention  to  the  walls  of  the 
wards,  in  addition  to  other  measures  of  cleanliness. 
The  hospital  building  was  an  old  one,  and  there  were 
many  cracks  in  the  walls.  Under  the  writer's  own 
supervision,  the  walls  were  thoroughly  washed  with 
soap  and  water,  the  ceilings  were  whitewashed  and 
all  cracks  were  injected  with  a  5  per  cent,  watery 
solution  of  carbolic  acid.     And  this  was  frequently 


84       PRINCIPLES   OF  TREATMENT   OF   BROKEN    LIMBS 

and  thoroughly  done  under  supervision,  as  a  matter 
of  routine. 

The  Hospital  after  that  procedure  was  more 
crowded  with  serious  open  wounds  than  ever  before, 
and  yet,  after  the  first  two  weeks,  when  the  system 
had  been  thoroughly  brought  into  efficient  operation, 
no  case  of  septiccemia  or  pycemia  ever  occurred  during 
the  writer's  charge  of  the  hospital  which  was  for  a 
peiiod  of  nearly  two  years.  As  a  gratifying  conse- 
quence the  death-rate  of  the  Hospital  was  reduced 
30  per  cent.,  although  retaining  many  operative  cases 
of  a  class  that  had  hitherto  been  transferred  to 
Bellevue  Hospital;  all  of  which  facts  were  made  a 
matter  of  official  record. 

On  account  of  this  successful  administration  of  the 
Park  Hospital,  especially  in  the  matter  of  suppress- 
ing the  occurrence  of  septicaemia  and  pyaemia,  the 
writer  was  appointed  to  take  charge,  in  addition,  of 
the  Ninety-ninth  Street  Reception  Hospital.  This 
latter  Hospital  cared  for  emergency  patients  in  the 
upper  part  of  the  City,  above  Fifty-ninth  Street.  It 
was  six  miles  distant  from  the  Park  Hospital,  sit- 
uated in  a  newer  and  fast  gi'owing  part  of  the  City 
where,  at  the  time,  many  public  improvements  were 
in  progress.  The  record  of  the  Ninety-ninth  Street 
Hospital  when  the  writer  assumed  sole  medical  and 
administrative  charge,  was  similarly  bad  as  regards 
infection  as  was  formerly  the  case  in  the  Park  Hos- 
pital. From  his  experience  in  the  Park  Hospital 
he  anticipated  no  doubt  that  the  same  measures  that 
had  been  so  conspicuously  successful  there  would  be 
equally  happy  in  their  results  when  vigorously  en- 


PRINCIPLES   OF  TREATMENT   OF   BROKEN   LIMBS      85 

forced  in  the  Ninety-ninth  Street  Hospital.  In  this, 
however,  he  was  disappointed.  It  is  true  that  the 
occurrence  of  septicEemia  was  reduced  in  frequency, 
nevertheless,  it  continued  to  occur,  and  the  writer 
recognized  that  his  measures  of  elimination  of  that 
infection,  though  strictly  carried  out,  were  only  par- 
tially successful. 

While  puzzling  to  discover  the  missing  contribu- 
tive  factor  causing  failure  of  his  efforts,  one  day  as 
he  was  turning  the  leaves  of  the  record-book  of  the 
very  large  Out-Patient  Service  connected  with  the 
Hospital,  he  was  struck  with  the  great  number  of 
patients  that  applied  and  were  treated  for  some  form 
of  malarial  poisoning.  Upon  investigation  he  found 
that  at  times  a  large  number  of  workmen  engaged 
in  digging  the  streets  in  the  vicinity  for  the  laying 
of  the  great  water-mains,  were  incapacitated  and  laid 
off  from  work  on  account  of  malarial  poisoning. 
Further,  every  member  of  the  House  Staff  living  in 
the  Hospital  had  been  at  times  affected  during  his 
residence,  and  frequently  members  of  the  Staff  were 
incapacitated  for  duty  on  that  account.  He  also 
noticed  that  otherwise  healthy  patients,  admitted  to 
the  Hospital  for  injuries  other  than  open  wounds, 
became  affected  with  malarial  poisoning  while  staying 
in  the  wards.  Added  to  this,  he  was  called  upon  to 
visit  a  patient  living  in  a  shack  next  to  the  Hospi- 
tal whom  he  found  dying,  distinctly  from  malarial 
poisoning. 

The  conclusion  was  irresistibly  forced  upon  the 
writer  that  the  Hospital  was  situated  in  a  zone  of 
intense  malarial  infection,  and  he  reasoned  that  the 


86      PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS 

depression  caused  by  that  poison  was  the  missing 
overlooked  factor  contributive  to  the  causation  of 
septicaemia  and  pyaemia  which  was  not  present  in  the 
Park  Hospital.  Accordingly,  he  gave  orders  that 
every  patient  admitted  into  the  Hospital  suffering 
from  any  open  wound  should  immediately  be  brought 
under  the  influence  of  quinine  and  that  a  mild  de- 
gree of  cinchonism  should  be  maintained  during  the 
whole  course  of  his  wound  treatment.  This  measure, 
combined  with  those  previously  instituted,  proved 
sufficient  to  control,  by  prevention,  the  further  oc- 
currence of  septicaemia  and  pyaemia.  Not  another  in- 
stance of  the  disease  occurred  thereafter,  during  the 
writer's  continued  charge  of  the  Hospital,  for  more 
than  a  year. 

The  battle  fought  by  the  writer  for  the  prevention 
of  septicaemia  and  pyaemia,  which  has  been  described 
somewhat  in  detail,  concerned  the  environment  of  the 
patient,  conditions  remote  from  the  wound.  It  re- 
lated to  what  may  be  termed  the  first  line  of  defense 
of  the  wound. 

In  Belle vue  Hospital,  in  preantiseptic  days,  for 
various  reasons,  interesting  in  themselves,  but  which 
in  adequate  consideration  would  extend  this  note  too 
far,  very  little  attention  was  paid  to  this  first  line  of 
defense.  The  members  of  the  Visiting  Staff  in  im- 
mediate authority  over  the  wards  were  constantly 
changing  service  and  consequently  there  was  no  ad- 
ministrative authority  alive  to  its  importance,  con- 
tinuously caring  for  this  defense.  In  the  progress 
of  years  great  attention  has  been  given  to  this  first 
line  of  defense  by  improved  hospital  construction 


PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS      87 

and,  equally  important,  in  hospital  organization  and 
management.  As  a  consequence  the  Hospital  which 
was  formerly  a  centre  of  infection  and  danger  has 
become  a  refuge  of  safety  in  its  model  construction 
and  intelligent  sanitation.  The  first  line  of  defense 
concerns  the  care  of  environing  conditions  remote 
from  the  wound.  The  second  line  of  defense  con- 
cerns the  proximate  distribution  of  conditions  of  the 
wound  itself. 

It  is  greatly  to  be  desired  that  "antiseptic  meas- 
ures" comprehended  in  the  second  line  of  defense 
should  be  standardized. 

How  often  has  the  writer  seen  a  surgeon  employ 
"antiseptic  measures"  which  would  have  proven  sadly 
defective  but  for  the  perfection  of  the  first  line  of 
defense.  Such  a  surgeon  would  have  resented  the 
imputation  that  the  complex  conditions  connoted  by 
his  "antiseptic  measures"  were  in  any  feature  defec- 
tive. Much  might  be  written  in  amplification  of  this 
point  which  is  left  to  the  reflection  of  the  thoughtful 
reader. 

Broadly  considered,  the  clinical  experiences  of  the 
writer  with  septicemia  and  pyemia  on  a  considerable 
scale  in  Bellevue,  Park,  and  Ninety-ninth  Street 
Hospitals,  seem  to  justify  certain  interesting  deduc- 
tions. 

In  Bellevue  Hospital  in  preantiseptic  days  the  in- 
tensity of  the  incident  cause  of  sepsis  was  fatal  in  a 
large  class  of  recent  wounds. 

In  the  Park  Reception  Hospital,  equally  infected 
as  Bellevue  Hospital,  the  surgical  and  administra- 
tive measures  narrated,  directed  against  the  incident 


88       PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS 

cause,  so  modified  that  variable  as  to  eliminate  the 
septic  wound  complications. 

In  the  Ninety-ninth  Street  Reception  Hospital, 
similarly  infected,  the  same  measures  directed  against 
the  incident  cause  that  were  so  strikingly  successful 
in  the  Park  Hospital  were  at  first  only  partially  suc- 
cessful. When,  however,  with  those  only  partially 
successful  measures  were  combined  other  measures 
combating  another  incident  cause  (malarial  poison- 
ing) the  results  were  as  good  as  those  obtained  in 
the  Park  Hospital. 

It  is  highly  improbable  that  the  measures  taken 
against  sepsis  were  operative  to  the  extent  of  totally 
excluding  the  incident  cause,  that  they  reduced  the 
number  of  germs  to  a  zero.  ISTevertheless,  the  varia- 
ble incident  cause  was  modified  to  that  degree  as  to 
be  harmless. 

The  incident  cause  of  sepsis  was  a  variable;  the 
incident  cause  in  combination  with  that  of  sepsis 
(malarial  poisoning)  was  also  a  variable. 

The  modifiable  malarial  influence  was  practically 
eliminated  or  reduced  to  harmlessness  by  means  of 
quinine,  thus  placing  the  patients  in  the  Ninety-ninth 
Street  Hospital  in  practically  the  same  relation  to 
sepsis  as  those  in  the  Park  Hospital,  insuring  a  like 
consequent  favorable  result. 

It  cannot  be  held  that  quinine  had  a  controlling 
specific  influence  over  the  septic  cause,  for  it  should 
be  remarked  that  quinine  had  been  tried  in  Bellevue 
Hospital  for  that  purpose,  even  by  the  writer,  and 
although  enormous  doses  of  the  medicine  had  been 
given,  it  had  only  shown  a  temporary  influence  over 


PRINCIPLES   OF   TREATMENT  OF   BROKEN   LIMBS      89 

the  temperatures  of  the  patients  and  no  apparent  in- 
fluence over  the  fatal  course  of  sepsis. 

It  is  also  interesting  to  note  (see  the  N.  Y.  Medi- 
cal Record,  June  7,  1890)  that  in  the  presence  of  the 
most  virulent  intensity  of  the  septic  cause  the  writer 
under  strict  antiseptic  precautions  performed  a  num- 
ber of  operations  of  suturing  simple  fractures  of  the 
patella  by  the  open  method  in  all  stages  and  condi- 
tions of  the  injury,  without  the  formation  of  pus  or 
the  occurrence  of  any  septic  complications  whatso- 
ever ;  and  that  this  was  done  and  the  results  achieved 
in  the  same  wards  where  compound  fractures  of 
the  patella,  before  the  introduction  of  antiseptic  treat- 
ment, were  otherwise  so  generally  fatal  that  the  writer 
regarded  a  prompt  primary  amputation  at  the  lower 
third  of  the  thigh,  the  site  of  election,  as  affording 
the  best  chance  of  saving  the  patient's  life. 


THE  OPEN  OPERATIOX  IX  THE  TREAT- 
MENT OF  SIMPLE  FRACTURES  CON- 
SIDERED IX  ITS  LOGICAL  RELATION 
TO  THE  ASSERTIOX  OF  A  XEGATIVE 

It  will  be  noted  that  the  extrinsic  splint  regarded 
as  a  part  of  a  truss  is  most  effective  when  it  can  be 
secured  in  relation  to  a  considerable  extent  of  the 
upper  and  lower  fragments.  The  joints  in  close  prox- 
imity to  the  false  points  of  motion,  must  of  necessity 
be  included  within  the  operation  of  the  truss.  It  is 
especially  difficult  to  obtain  a  grip  through  the  mass 
of  soft  tissues,  upon  the  upper  fragment  in  fractures 
near  the  hip- joint.  In  connection  with  particular 
difficulties  in  defining  categories  it  is  to  be  noted  that 
radiography  has  placed  within  the  hands  of  the  sur- 
geon a  wonderful  means  of  determining  the  exact 
condition  of  the  broken  bones.  As  the  difficulties  of 
accomplishing  extrinsic  control  over  adjustment  and 
immobilization  of  the  fragments  become  extreme,  the 
motive  for  using  intrinsic  appliances  gains  in  force. 

In  preantiseptic  days,  in  the  treatment  of  a  com- 
pound fracture  of  the  leg  with  much  mobility  at  the 
site  of  fracture  the  author  had  discarded  the  immov- 
able plaster-of-JParis  apparel  as  too  restrictive  of 
surgical  treatment  of  the  wound.  The  supports  of 
the  limb  sometimes  did  not  have  sufficient  control 

90 


PRINCIPLES    or   TREATMENT   OF   BROKEN    LIMBS      91' 

over  the  adjustment  of  the  fragments.  Occasionally 
in  such  cases  the  fragments  were  held  by  small  iron 
wire  staples.  Into  the  superficial  shell  of  each  frag- 
ment was  drilled  a  small  hole  and  then  the  staple  was 
lightly  hammered  into  place.  These  staples  had  only 
a  feeble  hold  upon  the  fragments  and  worked  loose 
in  three  or  four  days. 

To  act  more  efficiently  the  author  constructed  a 
bridge  or  truss  which  could  be  easily  taken  apart  or 
assembled.  It  was  made  of  steel  screws  carefully 
plated  and  a  connecting  member  of  soft  iron  that 
could  be  easily  bent  as  desired  with  tools  always  at 
hand.  First,  in  each  fragment  was  drilled  a  hole 
barely  large  enough  to  take  the  thread  of  the  screw. 
The  hole  went  through  the  superficial  shell  of  bone 
down  to  the  inner  surface  of  the  opposite  side  of  the 
shaft.  The  screws  were  then  driven  home,  their  ends 
resting  against  the  opposite  inner  surface  of  the 
shaft,  and  were  thus  firmly  implanted.  Next,  the 
fragments  were  adjusted  in  position  and  the  connec- 
ting member  consisting  of  the  strip  of  soft  iron  which 
was  slotted  near  its  ends  was  so  bent  that  it  could  be 
slid  into  position  in  the  open  slots  in  the  bodies  of  the 
screws  when  the  fragments  were  adjusted.  Then  iron 
wedges  were  pushed  into  the  slots  of  the  connecting 
member  filling  the  open  spaces  on  each  side  of  the 
bodies  of  the  screws.  Finally,  the  detachable  caps 
or  heads  of  the  screws  were  screwed  on,  consolidating 
the  bridge  or  truss  into  a  rigid  whole.  This  bridge 
or  truss  was  more  efficient  than  the  common  iron  wire 
staples,  yet  it  worked  loose  in  a  few  days  and  was 
removed.      The  drilling  did  not  seem  to  harm  the 


92      PRINCIPLES   OF  TREATMENT   OF   BROKEN   LIMBS 

bones.  The  drill-holes  speedily  filled  with  granu- 
lations. 

This  contrivance,  together  with  the  rest  of  the  com- 
plicated and  delicate  constructions  described,  was  dis- 
carded to  give  place  to  the  practice  of  antisepsis  w^hich 
placed  the  treatment  of  compound  fractures  and  the 
adaptation  of  extrinsic  apparel  in  a  category  closely 
approaching  that  of  simple  fractures. 

It  is  well  to  impress  upon  the  mind,  that  in  the 
formation  of  categories  in  which  given  incident  con- 
ditions embodied  in  treatment  are  the  subject  of 
negative  assertion,  a  single  successful  affirmative  in- 
stance in  the  given  category  is  logically  destructive 
of  the  universality  of  distribution  of  the  negative  as- 
sertion essential  to  the  validity  of  argument.  For 
example,  it  may  be  said  that  in  the  category  of  re- 
cent oblique  simple  fractures  in  the  lower  third  of 
the  shaft  of  the  femur  with  much  shortening,  the 
open  operation  with  intrinsic  fastening  of  the  bony 
fragments  is  necessary,  which  is  tantamount  to  as- 
serting the  denial  that  in  the  given  category  other 
methods,  perhaps  embodied  in  extrinsic  apparel,  are 
productive  of  equally  good  union  of  the  bones  in  cor- 
rect position.  This  negative  assertion  derives  its 
logical  force  from  the  universality  of  its  distribution. 
A  single  successful  instance  of  treatment  by  extrinsic 
support  limits  the  universality  of  that  distribution, 
destroys  the  validity  of  the  argument  and  leads  to 
the  necessity  for  the  creation  and  definition  of  new 
categories. 

The  photographs  (see  Plate  XVIII)  show  dif- 
ferent views  of  a  specimen  of  an  oblique  fracture  at 


Cd. 


'X 


OCKt.  <,y. .'  .■£  ^M2I>C^'  ^: -/■WBfiMr^snracii 


PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS      93 

the  lower  end  of  the  shaft  of  the  femur  which  has 
not  only  an  interesting  history,  but  strikingly  illus- 
trates the  meaning  of  what  has  been  said  regarding 
an  affirmative  instance  limiting  the  universality  of 
distribution  of  the  negative  proposition. 

The  patient  from  whom  the  bone  was  taken  was 
the  first  instance  of  fracture  of  the  shaft  of  the  femur 
which  was  ever  treated  by  the  author.  Shortly  be- 
fore admission  to  the  Hospital  the  patient  suffered 
from  a  simple  fracture  of  the  shaft  of  the  femur  from 
direct  violence  with  considerable  shortening  of  the 
limb.  There  was  little  tendency  to  swelling  of  the 
injured  soft  parts.  The  writer  applied  an  immov- 
able plaster-of-Paris  splint  immediately.  The  patient 
was  out  of  bed  in  a  day  or  two,  walking  about  on 
crutches.  He  made  an  uneventful  recovery.  Upon 
removal  of  the  splint,  only  one  having  been  applied, 
the  fragments  were  found  united  without  shortening 
or  other  deformity.  In  time  the  patient  was  dis- 
charged, cured,  from  the  Hospital. 

Several  weeks  later  he  was  admitted  into  a  medical 
ward  of  the  same  institution  suffering  from  nephritis 
from  which  he  died. 

The  bone,  through  the  many  years  it  has  been  kept, 
has  suffered  some  disintegi'ation  at  its  spongy  ends 
but  without  impairment  of  its  value  as  a  specimen 
of  united  fracture  without  deformity  treated  in  the 
plaster-of-Paris  splint.  The  osteophyte  is,  of  course, 
extraneous  to  the  subject  under  consideration.  It 
will  be  observed  that  although  the  line  of  fracture 
was  oblique  in  the  extreme,  the  union  was  in  all  re- 
spects a  perfect  one. 


94      PEINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS. 

The  union  of  the  fragments  in  perfect  adjustment 
as  regards  deformity  shown  in  this  photograph  of  the 
fracture  at  the  lower  third  of  the  femur  was  achieved 
before  the  discovery  of  radiography,  when  it  was 
therefore  impossible  to  show  the  perfection  of  results 
in  life  as  by  an  exhibit  of  the  bone  itself. 

So  far  as  tests  could  be  made  by  measurements 
and  otherwise,  perfect  results  like  that  shown  in  the 
author's  instance  were  the  common  occurrence.  This 
is  even  well  shown  through  the  applied  splints  in  the 
photograph  of  the  patient  with  fracture  at  the  middle 
of  both  thighs. 

The  results  were  often  so  perfect  that  the  writer 
himself  has  sometimes  heard  a  celebrated  authority, 
averse  to  the  method  for  personal  reasons,  declare  in 
examining  some  patients  that  he  had'  no  evidence  that 
the  thigh-bone  had  ever  been  broken. 

The  objection  to  the  use  of  the  immovable  plaster- 
of-Paris  splint  in  treating  simple  fractures  of  the  shaft 
of  the  femur  was  not  directed  against  the  character 
of  the  results  achieved,  which  in  expert  hands  were 
conspicuously  superior  to  those  of  other  methods  then 
in  use,  but  was  against  the  necessity  of  using  that 
high  degree  of  skill  for  its  perfect  construction  only 
possible  at  the  hands  of  trained  operators. 

The  use  of  the  splint  was  therefore  not  primarily 
a  question  of  results  but  of  skill.  The  important 
question  arises,  should  skill  be  cultivated  to  that  de- 
gree capable  of  attaining  results  of  higher  value,  or, 
should  inferior  results  be  accepted,  that  are  within 
the  reach  of  a  lower  degree  of  skill  and  consequently 
more  generally  obtainable.     To  avoid  an  easy  appli- 


PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS      95 

cation  of  the  reductio  ad  absurdum  to  the  argument 
for  lowering  the  aini  in  accommodation  to  a  lower 
degree  of  skill,  but  one  answer  is  possible.  Clearly, 
skill  should  be  cultivated  to  the  degree  of  obtaining 
results  of  higher  value.  Such  cultivation  of  skill  be- 
longs to  the  function  of  educators.  Since  practice 
founded  upon  experience  is  a  necessary  qualification 
in  such  education,  it  follows  that  some  degree  of 
specialization  will  probably  be  necessary  to  furnish 
the  needed  instances  for  experience. 

It  will  be  noted  that  some  of  the  open  operations 
on  fractures  of  long  bones  now  somewhat  in  vogue 
are  performed  to  correct  the  results  of  initial  faulty 
treatment.  For  that  purpose  they  are  a  valuable 
resource.  Such  instances  lack  force  in  an  argument 
against  the  original  procedures  when  properly  per- 
formed and  speak  loudly  for  the  cultivation  of  skill 
since  proper  measures  of  treatment  carried  out  with 
adequate  skill  in  the  first  instance  might  have  pro- 
duced satisfactory  results,  thus  doing  away  alto- 
gether with  the  need  of  the  corrective  measures  of  the 
open  operation. 

The  argument  for  the  general  performance  of  the 
open  operation  is  not  parallel  to,  or  comparable  in 
cogency  with,  that  of  the  open  operation  for  suturing 
simple  fractures  of  the  patella.  In  the  latter  class 
of  injuries  the  infolded  fringe  of  tissue  practically 
always  prevents  contact  of  the  bony  surfaces  in  ap- 
position, and  the  open  operation  is  therefore  neces- 
sary to  lift  away  the  interposed  tissue  to  insure  bony 
imion.  In  fractures  of  the  long  bones  generally,  in- 
terposition of  tissues  sufficient  to  prevent  union  under 


96       PRINCIPLES    OF   TREATMENT   OF   BROKEN    LIMBS 

proper  methods  of  treatment  is  a  rarity.  The  author 
has  never  seen  but  one  instance.  In  that  injury,  a 
compound  fracture  of  the  leg,  the  loose,  detached 
transversely  interposed  fragment  was  easily  removed. 
The  burden  of  proof  rests  upon  the  operating  sur- 
geon to  show  that  such  an  interposition  of  tissue  or 
other  adverse  condition  exists  in  the  given  instance 
to  constitute  a  bar  to  union  or  union  without  deform- 
ity under  the  best  prescribed  conditions  of  treatment, 
consequently  creating  the  necessity  of  the  open  opera- 
tion. While  deprecating  the  procedure  as  a  routine 
measure  the  writer  does  not  deny  that  exceptionally 
such  states  of  fracture  may  occur  and  consequently 
that  infrequently  the  open  operation  may  be  advis- 
able as  a  primary  procedure. 

If  there  exist  categories  of  conditions  of  the  frac- 
ture of  the  shaft  of  the  femur  either  in  location  or 
character  of  the  fracture  in  which  the  non-operative 
treatment  would  fail  in  producing  like  happy  results 
to  the  one  shown  in  the  writer's  specimen,  it  is  highly 
important  that  such  categories  embracing  the  excep- 
tions should  be  accurately  defined. 

In  view  of  the  large  number  of  successful  instances 
in  which  union  without  shortening  or  other  deformity 
has  been  achieved  by  skilled  surgeons  throughout  dif- 
ferent regions  of  the  shaft  of  the  femur  under  a  wide 
range  of  conditions  of  fracture,  and  under  different 
procedures  of  treatment,  the  great  difficulty  in  cre- 
ating and  defining  categories  of  exceptions  in  which 
the  open  operation  is  a  necessity  is  evident. 

It  is  always  to  be  remembered  that  a  single  success- 
ful exception  in  any  such  created  category  by  limit- 


PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS      97 

ing  the  universality  of  distribution  of  the  negative 
proposition  vitiates  the  logical  force  of  the  category  in 
substantiating  the  assertion  of  the  negative,  that  is, 
in  asserting  the  denial  of  the  sufficiency  of  some  non- 
operative  method  to  attain  the  proposed  good  result. 

The  burden  of  proof  in  justifying  their  action 
rests,  of  course,  with  those  who  would  assert  the  nega- 
tive. The  force  of  such  proof  must  be  overwhelming 
to  justify  as  a  routine  method  of  treatment  the  con- 
version of  recent  simple  fractures  into  compound 
fractures,  when  results  equally  good  or  superior  may 
be  obtained  without  inflicting  a  serious  superadded 
and  unnecessary  wounding  of  the  patient  and  expos- 
ing him  to  the  risk  of  infection,  which,  when  it  occurs 
in  fractures  of  the  shaft  of  the  femur  is  a  serious 
disaster.  When  suppuration  has  spread  among  the 
muscular  planes  of  the  thigh  the  author  is  of  the 
opinion  that  amputation  affords  the  most  efficient 
drainage. 

The  patient  with  simple  fracture  of  both  thighs 
(see  Plates  X  and  XI)  would  have  been  in  a  pitiable 
plight  had  he  been  treated  by  the  unnecessary  open 
operation,  wherein,  according  to  one  apostle  of  the 
method,  "The  incision  which  is  always  long"  is  "from 
eight  to  ten  inches."  It  is  further  to  be  noted  the 
intrinsic  means  "must  be  considered  only  of  value 
merely  to  approximate  the  fragments  and  not  at  all 
sufficient  to  hold  them.  For  this  purpose  the  whole 
reliance  must  be  placed  upon  the  solid  external  plas- 
ter case,  most  accurately  and  carefully  applied.  If 
this  does  not  succeed  in  absolutely  immobilizing  the 
fragments,  the  operation  may  fail." 


98       PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS 

In  view  of  occasional  fallacies  it  is  to  be  noted  that 
a  bad  result  consequent  upon  an  error  in  judgment, 
fault  of  skill,  or  from  any  cause,  in  the  performance 
of  this  operation,  as  in  the  case  of  all  operations,  does 
not  in  itself  constitute  a  basis  for  argument  against 
the  value  of  the  result  obtained  in  the  successfully- 
performed  operation. 

The  author  quotes  in  full  from  a  recent  Hospital 
Report  omitting  the  confirming  radiographs,  the  re- 
port of  a  successful  instance  of  non-operative  treat- 
ment of  a  simple  subtrochanteric  fracture  of  the 
femur,  as  an  instance  limiting  the  universal  distribu- 
tion of  the  negative  proposition  and  therefore  de- 
structive to  the  validity  of  the  argument  in  favor  of 
the  necessity  of  the  open  operation  for  the  given 
group  of  patients. 

"Two  weeks  previous  to  admission  this  patient,  a 
lady  forty-eight  years  of  age,  had  sustained  this  in- 
jury while  on  vacation  in  the  country.  When  brought 
to  the  city  and  admitted  to  hospital  the  .  .  .  upper 
fragment  was  flexed  and  abducted  and  the  lower 
fragment  was  drawn  upward  producing  a  shortening 
of  one  and  a  quarter  inches. 

"The  patient  was  somewhat  stout  in  habit  and  of 
highly  nervous  temperament.  The  difficulties  to  be 
overcome  in  securing  satisfactory  reposition  of  the 
fragments  were  appreciated.  We  were  familiar  with 
the  fact  that  in  this  class  of  fractures  position  and 
traction  are  usually  so  inefficient  in  overcoming  dis- 
placement that  such  a  fracture  is  recognized  as  one 
in  which  exposure  and  plating  are  especially  indi- 
cated.    We  hesitated  therefore  to  rely  on  position 


PRINCIPLES   OF  TREATMENT   OF   BROKEN   LIMBS      99 

and  traction  in  this  case,  notwithstanding  that  in  no 
case  of  this  kind  previously  under  our  care  had  we 
failed  to  get  a  satisfactory  result  either  as  regards 
function,  deformity  or  length. 

"But  in  this  particular  case,  taking  into  account  the 
length  of  time  since  the  injury  had  been  sustained 
and  the  peculiar  physical  and  temperamental  status 
of  the  patient,  we  earnestly  advised  that  the  fracture 
should  be  exposed  and  coaptation  secured  by  plating. 
The  patient  herself,  however,  would  not  accept  this 
proposition,  but  insisted  that  first  a  non-operative 
treatment  should  be  tried.  This  was  therefore  in- 
stituted. A  slight  flexion  was  obtained  by  keeping 
the  leg  on  a  sliding  Volkmann's  apparatus,  which 
also  reduced  to  a  minimum  the  friction  resistance  to 
the  full  effect  of  the  extension  traction.  Counter-ex- 
tension was  provided  not  only  by  elevating  the  foot 
of  the  bed,  but  also  by  the  use  of  a  suitable  perineal 
band  secured  to  the  head-post  of  the  bedstead.  A 
pelvic  band  held  the  pelvis  to  the  side  of  the  bed  cor- 
responding to  the  sound  limb,  so  that  by  placing  the 
traction  pulley  at  the  foot  of  the  bedstead,  close  to 
the  opposite  post,  a  good  angle  of  abduction  was  se- 
cured. The  perineal  counter-extension  band,  the  pel- 
vic lateral  band,  the  sliding  leg  support  and  abduct- 
ing extension  adhesive  strips,  kept  taut  by  the  weight 
at  their  end,  all  formed  a  very  excellent  confining 
harness  that  still  was  not  intolerable,  and,  as  the  event 
proved,  was  well  borne  by  an  unusually  restless  and 
intolerant  individual.  This  traction  weight  was  rap- 
idly increased  up  to  twenty-five  pounds.  This  was 
well  borne  and  within  a  few  days  the  length  of  the 


100      PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS 

injured  limb  was  brought  to  the  same  measurement 
as  that  of  the  sound  one.  Consolidation  proceeded 
in  normal  rapidity  and  at  the  end  of  ten  weeks  the 
patient  walked  out  of  the  hospital  with  the  aid  of 
crutches.  .   .   . 

* 'Examination  made  four  months  later  confirmed 
the  facts  that  the  length  of  the  two  limbs  was  equal 
and  that  no  deformity  was  exhibited  by  the  injured 
thigh. 

"We  are  reporting  this  case  somewhat  fully,  not 
with  a  view  of  in  any  way  reflecting  upon  the  value  or 
propriety  of  subjecting  such  injuries  frequently  to 
exposure  by  incision  and  to  plating,  but  as  an  ex- 
ample of  the  possibility  of  securing  excellent  results 
by  more  conservative  methods  whenever  for  good 
reasons  prudence  dictates  the  avoidance  of  special 
hazards  which  must  always  attend  the  more  radical 
and  perhaps  more  eflicient  operative  methods." 

The  foregoing  instance,  which  in  its  logical  bearing 
will  repay  the  most  thoughtful  study,  establishes  by 
strongest  proof  that  for  the  specified  patient  the  open 
operation  by  incision  and  plating  was  not  an  opera- 
tion of  necessity.  This  conclusion  is  placed  beyond 
doubt  by  the  statement  of  the  surgeon  himself. 

The  eminently  able  surgeons  in  charge  of  the  pa- 
tient, on  account  of  the  unusual  length  of  time  that 
had  elapsed  between  the  time  of  the  occurrence  of  the 
injury  and  the  date  of  the  beginning  of  treatment, 
together  with  peculiarities  of  temperament  of  the  pa- 
tient, were  inclined  to  doubt  that  the  specific  instance 
could  be  included  in  that  category  of  which  they  af- 
firmed "in  no  case  of  this  kind  previously  under  our 


PRINCIPLES   OF  TREATMENT   OF   BROKEN   LIMBS      101 

care  had  we  failed  to  get  a  satisfactory  result  either 
as  regards  function,  deformity  or  length."  The  event 
proved,  however,  that  the  patient  was  no  exception, 
belonging  to  a  different  category  calling  for  other 
conditions  of  treatment. 

Admitting  that  the  open  operation  by  incision  and 
plating  could  have  secured  equally  good  union  of 
the  fragments  in  correctly  adjusted  position  as  that 
which  was  actually  achieved  by  the  non-operative 
treatment,  the  impersonal  proof  of  the  comparative 
value  of  the  differing  methods  of  treatment  open  to 
choice  remains  to  be  established. 

It  is  not  enough  to  verify  the  facts  comprehended 
in  given  results,  the  comparative  value  of  these  re- 
sults in  their  elements  of  dissimilarity  must  be  proven. 
This  being  accomplished,  the  conduct  of  the  surgeon 
in  adopting  his  choice  of  methods  is  governed  by 
ethics,  and  is  under  the  control  of  the  social  organism. 


TREATMENT  OF  SEPTIC  WOUND  COM- 
PLICATIONS;  COMPOUND   FRACTURES 
AND  PRIMARY  AMPUTATIONS 

The  practice  of  acute  septic  surgery  is  a  delicate 
branch  of  surgical  art  requiring  trained  judgment 
and  educated  hands  to  promptly  deal  with  the  quick 
changes  in  the  tissues. 

Septic  patients  stand  the  loss  of  blood  badly;  a 
very  small  additional  loss  of  blood  being  enough  to 
turn  the  scales  fatally  against  them. 

In  the  treatment  of  septic  compound  fractures  and 
amputations  it  is  a  great  error,  the  author  conceives, 
to  bandage  absorbent  dressings  about  the  wound. 
The  disturbance  of  the  inflamed  septic  tissues  in  the 
act  of  changing  dressings  alone  inflicts  great  injury. 
Such  tissues  have  very  feeble  resistance  and  do  not 
tolerate  handling,  not  to  speak  of  the  dissemination 
of  the  infective  material.  Such  wounds  should  be  left 
undisturbed,  at  complete  functional  and  ph5^sical  rest. 

The  apparatus  devised  by  the  author  for  the  treat- 
ment of  amputations  of  the  thigh,  the  arm  and  fore- 
arm, together  with  compound  fractures  in  the  upper 
extremity,  was  very  simple  in  its  construction  and 
satisfactory  in  its  action,  and  might  be  especially  ser- 
viceable in  militai*y  surgery.  It  is  well  shown  in  the 
instance  of  the  treatment  of  the  amputation  of  the 

102 


PLATE    XII. 

Recent  Primary  Amputation  at  the  Thigh,  Treated  by  Suspen- 
sion on  Frame.  Duplicate  clean  frame  shown  at  the  right. 
No  dressings  upon  the  wound. 


PLATE    XIII. 

Recent  Primary  Amputation  at  the  Thigh.  The  clean  support 
has  been  substituted  for  soiled  support.  Strips  of  soiled 
support  are  being  removed.  Wire  of  soiled  frame  has  been 
lifted  away  in  removal.     No  dressings  upon  the  wound. 


PRINCIPLES   or   TREATMENT   OF   BROKEN   LIMBS      103 

thigh.  It  consists  of  a  steel  wire  about  one-fourth 
of  an  inch  in  diameter,  bent  to  conform  to  the  general 
outline  of  the  limb.  The  wire  is  given  a  spring  out- 
ward to  keep  the  covering  of  the  frame  upon  the 
stretch.  The  branches  of  wire  are  tied  the  proper 
distances  apart.  The  skeleton  wire  frame  is  covered 
by  bandaging  with  one  inch  wide  bandage. 

To  cover  the  frame  with  bandage,  an  assistant  holds 
the  frame  at  the  open  end,  keeping  upon  the  stretch 
the  piece  of  bandage  holding  the  branches  of  wire  the 
proper  distance  apart.  The  surgeon,  beginning  at  the 
closed  end  of  the  frame,  ties  the  end  of  the  bandage 
to  his  left-hand  wire.  He  carries  the  bandage  to  the 
upper  surface  of  the  right  hand  wire,  around  which 
he  makes  one  and  a  half  turns.  In  making  the  last 
half  turn  the  bandage  is  made  to  encroach  upon  one- 
half  of  the  width  of  the  turn  already  made,  thus  tying 
the  bandage  to  the  wire.  From  the  under  surface  of 
the  right  hand  wire  the  bandage  passes  to  the  under 
surface  of  the  opposite  or  left  hand  wire,  around  which 
one  and  a  half  turns  are  made,  the  last  half  turn  in- 
fringing upon  or  overlapping  one-half  the  width  of 
the  turn  of  the  bandage  already  made,  fastening  the 
bandage  to  the  wire.  From  the  upper  surface  of  the 
left  hand  wire  the  bandage  is  continued  across  the 
frame  to  the  upper  surface  of  the  right  hand  wire, 
being  applied  about  the  wire  slightly  in  advance  of 
the  previous  turn  already  made. 

Some  little  degree  of  practice  is  required  to  make 
the  bandage  covering  of  the  frame  of  even  tension, 
and  to  tie  the  bandage  firmly  round  each  branch  of 
wire.      When    properly    constructed,    the    covering 


104      PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS 

bandage  is  so  firmly  secured  to  each  wire  that  neigh- 
boring slips  may  be  cut,  and  the  uncut  adjoining  slips 
will  still  hold  fast  to  the  wire  and  support  the  tissues, 
as  shown  in  the  illustrations.  The  covered  frame  is 
tied  at  its  ends  to  a  bandage  passed  around  the  pa- 
tient's body.  The  frame  sustaining  the  limb  is  then 
suspended  from  the  apparatus  already  described  by 
lengths  of  wire  picture-cord  having  hooks  at  each  end, 
all  of  which  can  be  easily  made  by  the  surgeon,  the 
limb  resting  upon  the  support  without  any  dressing 
of  the  wound  whatever.  To  prevent  the  skin  sticking 
to  the  frame  the  latter  is  smeared  at  the  proper  place 
with  some  kind  of  simple  ointment.  An  excess  of  pus 
from  the  wound  drains  away  between  the  narrow 
strips  of  bandage  covering  the  frame;  this  drainage 
may  be  facilitated  by  snipping  holes  in  the  support 
without  impairing  its  integrity.  To  change  the 
treated  wound  to  a  clean  frame,  a  duplicate  frame 
covered  with  bandage  is  slid  beneath  the  soiled  one 
upon  which  the  limb  rests.  The  hooks  are  changed 
from  the  upper  to  the  lower  frame;  the  covering  of 
bandage  is  cut  all  around  near  the  wire  of  the  soiled 
frame  beginning  at  the  open  end  of  the  frame,  thus 
freeing  the  wire ;  the  cut  slips  of  bandage  of  the  upper 
frame  are  then  drawn  down  between  corresponding 
ones  forming  the  covering  of  the  fresh  support, 
pulled  away  and  discarded.  In  the  very  amputation 
of  the  thigh  shown  in  the  illustration  a  fresh  new 
frame  supporting  the  thigh  was  substituted  for  the 
soiled  one  without  awakening  the  patient  from  sleep. 
In  the  case  of  the  leg  where  there  is  much  change 
in  contour  the  support  cannot  be  made  in  one  piece 


PLATE    XIV. 

Recent  Primary  Amputation  of  tlie  Forearm,  Treated  by  Suspen- 
sion, without  Dressings  upon  the  Wound. 

Upper  Figure. — Clean  frame  beneath  soiled  frame. 
Middle  Figure. — Wire  of  soiled  frame  removed. 
Lower  Figure. — Limb  resting  upon  clean  frame. 


PLATE    XVI. 

Upper  Figure. — Compound  Fraeture  of  the  Leg,  Treated  in 
a  Fracturc-box'. 

Lower  Figure. — Same  Com])ound  Fracture  of  tlie  Leg, 
Treated  in  Suspension  Apparatus  with  Sectional  Supports. 


PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS      105 

but  must  be  divided  into  sections.  Plate  XV  shows 
a  double  amputation,  a  Syme  and  a  Stephen  Smith 
side-flap  amputation  treated  upon  sectional  supports. 

Plate  XVI,  upper  figure,  shows  a  compound  frac- 
ture of  the  leg  which  is  under  treatment  in  a  fracture- 
box.  Several  incisions  have  been  made  to  deal  with 
spreading  suppuration.  Obviously,  had  the  limb 
been  treated  in  a  plaster-of-Paris  splint  the  splint 
would  have  been  restrictive  of  those  surgical  measures 
demanded  by  the  wound  complications.  In  dressing 
or  changing  into  a  clean  fracture-box  the  limb  was 
necessarily  disturbed  in  violation  of  one  of  the  car- 
dinal principles  of  treatment  of  septic  wounds,  which 
demands  that  the  limb  be  kept  at  physical  rest,  and, 
if  possible,  not  even  handled.  In  the  fracture-box  the 
lower  fragment  remains  stationary,  while  the  slight- 
est motion  of  the  patient  disturbs  the  upper  fragment. 

Plate  XVI,  lower  figure,  shows  the  same  limb  in  ap- 
paratus which  permits  the  freest  surgical  functioning 
while  the  fragments,  as  shown  by  the  outline  of  the 
limb,  are  preserved  in  even  better  position  than  in 
the  fracture-box.  The  sectional  supports  are  so  con- 
trived that  any  one  or  two  of  them  may  be  tempora- 
rily removed  without  impairing  the  efficiency  of  the 
general  support  of  the  limb.  No  dressings  are  used 
except  a  piece  of  lint  spread  with  some  simple  oint- 
ment to  cover  the  granulating  surfaces.  The  sectional 
supports  are  of  bandage  carried  by  a  single  iron  vrire 
bent  into  such  form  that  when  the  section  supports 
the  limb  there  is  no  contact  of  the  wire  with  the  tis- 
sues. The  supports  are  adjustable  by  means  of  the 
links  of  the  chain  catching  into  the  hooks  fastened  to 


106      PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS 

the  steel  frame.  Provision  is  made  for  balancing  the 
limb  and  for  its  elevation  or  depression. 

The  construction  shown  in  Plate  XVII  was  a  de- 
velopment of  that  shown  in  Plate  XVI,  lower  figure. 
It  was  designed  to  exert  a  greater  control  over  the 
fragments.  A  base  line  was  provided  by  the  use  of  a 
square  brass  bar  which  while  strong  enough  to  hold 
the  suspended  limb  yet  could  be  bent  by  the  surgeon 
into  desired  form.  To  make  the  bar  adjustable  in 
length  for  use  upon  different  limbs  it  was  cut  in  two, 
and  the  two  portions  firmly  held  together  by  two 
clamps  (see  Plate  XVII,  lower  figure) .  The  bar  was 
drilled  transversely  throughout  its  length,  making 
holes  about  an  inch  apart.  At  first  these  holes  were 
made  only  large  enough  to  receive  snugly  the  small 
hard  brass  wires  carrying  the  sectional  supports.  It 
was  so  constructed  that  when  the  sectional  supports 
were  in  position  the  friction  alone  developed  by  the 
weight  of  the  limb  would  hold  immovable  the  wires 
passed  through  the  bar. 

It  was  found  desirable,  however,  on  account  of 
wear  to  be  able  to  key  the  wires  in  any  given  position. 
This  was  done  by  drilling  another  hole  of  the  same 
size  alongside  and  infringing  upon  the  holes  already 
made  through  the  bar.  Consequently  a  small  piece 
of  brass  wire  like  that  used  in  the  sectional  supports, 
bent  at  a  right  angle  and  slightly  tapered  at  one  end, 
could  be  pushed  into  the  second  hole  keying  the  wire 
fast  that  had  been  passed  through  the  hole  alongside. 
By  this  means  the  carrying  wire  of  the  sectional  sup- 
port could  be  held  in  position  with  great  accuracy  of 
adjustment. 


PLATE    XVII. 

Upper  Figure. — Compound  Fracture  of  the  Leg.  Treated 
by  Suspension  and  with  Sectional  Supports.  Two  supports  and 
part  of  a  third  have  been  removed  and  an  abscess  incised. 

Lower  Figure. — Excision  of  the  Knee-joint.  Treated  bv 
Suspension  and  with  Sectional  Supports.  No  wiring  or  nailing 
of  the  bones. 


PRINCIPLES   OF  TREATMENT   OF   BROKEN   LIMBS      107 

Two  crossbars  mounted  upon  the  carrying  wire 
held  the  bandage  constituting  the  sectional  support. 
A  narrow  bandage  was  easily  fastened  to  the  cross- 
bars in  the  same  manner  that  the  bandage  covered  the 
frames  used  to  support  the  amputation  of  the  thigh 
(see  Plate  XVII,  upper  figure).  Thus  constructed 
even  a  portion  of  the  bandage  of  the  sectional  support 
could  be  cut  away  and  the  remaining  portion  of  the 
bandage  would  hold  fast  (see  Plate  XVII,  upper 
figure).  The  bar  constituting  the  base  line  was  fast- 
ened at  one  end  to  a  band  of  simple  webbing  which 
made  one  turn  of  a  spica  about  the  pelvis.  The  other 
end  of  the  bar  was  bandaged  to  the  foot  in  the  man- 
ner shown,  holding  it  so  it  would  not  shift  from  posi- 
tion. Thus  conditioned  the  injured  limb  while  in  ab- 
solute rest  was  in  an  attitude  for  extended  surgical 
functioning.  It  was  open  to  inspection,  palpation 
and  surgical  treatment.  The  suspension  of  the  limb 
was  adjustable  and  the  patient  enjoyed  a  consider- 
able range  of  motion  without  disturbing  the  immo- 
bility of  the  adjusted  fragments. 

The  advent  of  the  antiseptic  treatment  of  wounds 
led  the  author  to  discard  the  use  of  the  special  ap- 
paratus described.  Through  effective  antisepsis 
compound  fractures  were  brought  into  a  category 
closely  approaching  simple  fractures,  and  treated  ac- 
cordingly. 

While  the  complex  of  conditions  comprehended 
under  the  term  antiseptic  measures  may  be  easily  for- 
mulated, it  is  to  be  borne  in  mind  that  the  practical  ap- 
plication of  those  measures,  and  full  realization  in 
practice  of  antisepsis  depend  upon  the  surgeon  him- 


108      PRINCIPLES    OF   TREATMENT   OF   BROKEN    LIMBS 

self,  a  factor  of  the  first  importance,  although  of 
great  and  incalculable  variability. 

It  is  almost  amusing  to  note  in  surgical  literature 
how,  sometimes,  a  surgeon,  in  excusing  unfortunate 
mishaps,  has  sought  to  limit  the  range  of  antiseptic 
efficiency  by  naively  "begging  the  question"  in  refer- 
ence to  his  own  employment  of  antiseptic  measures. 

It  will  be  observed  (Plates  XII  and  XIV)  that 
the  amputations  of  the  thigh  and  forearm  are  placed 
in  a  state  of  physical  rest.  The  tissues  are  also  so 
conditioned  as  to  be  capable  of  an  extended  range 
of  surgical  functioning  and  are  not  necessarily  sub- 
jected to  any  special  therapeutic  influence. 

It  is  emphasized,  in  repetition,  that  the  discarded 
apparatus  has  been  described  not  in  any  special  ad- 
vocacy of  its  use,  but  in  exposition  of  the  extension 
of  the  principles  which  it  embodied. 

The  author  not  using  dressings  upon  wounds  be- 
came unaccustomed  to  expressions  of  pain  on  the 
part  of  patients  in  the  usual  dressing  of  their  com- 
pound fractures  and  amputations  and  as  a  conse- 
quence well  recalls  the  following  incident : 

On  a  visit  to  a  large  surgical  hospital  the  author 
was  invited  by  the  distinguished  and  veteran  surgeon 
who  had  operated  upon  the  patient  to  witness  the 
dressing  of  a  recent  primary  amputation  of  the  thigh 
in  which  he  took  particular  pride. 

At  the  surgeon's  approach  the  patient's  face  be- 
came clouded  with  anxiety.  The  wound  dressing 
consisted  in  binding  a  quantity  of  loosely  shaken, 
fluffy  oakum  about  the  stump.  After  the  removal  of 
the  old  dressing,  which  was  sodden  with  decomposed 


PRINCIPLES   OF   TREATMENT   OF   BROKEN    LIMBS      109 

pus,  an  assistant  industriously  squeezed  the  stump 
till  the  last  drop  of  pus  was  expelled  from  the  sinuses 
communicating  with  the  wound.  The  wound  and 
connecting  sinuses  were  then  thoroughly  syringed 
with  a  watery  solution  of  carbolic  acid,  and  finally 
the  new  oakum  dressing  was  bandaged  to  the  stump. 
In  doing  this,  an  assistant  stood  upon  the  bed  astride 
the  patient,  whom  he  lifted  while  the  bandage  was 
being  carried  around  the  pelvis.  At  last,  the  patient 
sank  back  exhausted  and  exclaimed:  "For  God's 
sake,  doctor,  stop  and  let  the  wound  have  a  chance 
to  heal!" 

The  observed  procedures  were  justified  by  preva- 
lent practice,  and  were  carried  out  under  the  direc- 
tion of  the  operating  surgeon  who  did  not  seem  to 
realize  that  his  patient,  in  the  dressing  of  his  wound, 
lost  as  much  energy  in  a  higher  form,  as  would  have 
followed  a  considerable  blood-letting.  According  to 
the  author's  usual  procedure  all  that  wasted  energy 
accompanied  by  manifestations  of  pain  would  have 
been  saved  to  the  patient. 


SCOPE  OR  DEGREE  OF  EXTENSION 
CONSIDERED  IN  REFERENCE  TO 
PRINCIPLES  EMBODIED  IN  SURGI- 
CAL   PROCEDURES 

In  the  comparison  of  methods  of  treatment  the 
consideration  of  scope  or  the  degree  of  extension  of 
embodied  principles  is  of  great  importance. 

For  example,  in  the  case  of  the  tin  strips  it  has 
been  stated  that  the  fixation  of  the  bony  fragments 
in  a  given  relation  is  achieved  in  a  minimum  time. 
Increase  of  speed  in  immobilizing  the  fragments  is 
in  itself  an  increase  of  scope. 

Furthermore,  the  strips  may  be  fastened  in  posi- 
tion, thereby  insuring  the  quick  fixation  of  the  bone 
either  by  a  dry,  wet,  plaster-of-Paris,  starch,  water- 
glass  or  other  kind  of  bandage  that  may  be  chosen 
for  the  construction  of  the  enveloping  apparel.  This 
is  an  increased  range  of  choice  of  material  in  the  con- 
struction of  the  permanent  splint. 

Increased  scope  is  illustrated  in  the  use  of  the 
writer's  crochet-drill  in  the  suturing  of  simple  frac- 
tures of  the  patella  by  the  open  operation,  the  es- 
sential element  of  the  operation  being  the  holding 
of  the  fragments  in  the  desired  relation  by  suturing. 

In  usual  drilling  when  the  drill  is  withdrawn,  tis- 
sues are  apt  to  slip  over  and  obscure  the  drill  hole, 
making  the  passing  of  the  suture  very  difficult. 

no 


PRINCIPLES    OF   TREATMENT    OF    BROKEN    LIMBS      111 


Again,  the  fragments  must 
often  be  tilted  or  the  joint  flexed 
to  enable  the  operator  to  secure 
the  end  of  the  suture  as  it  merges 
upon  the  under  surface  of  the 
bone  at  a  definite  point.  In  other 
words,  the  efficiency  of  the  ordi- 
nary drill  is  restricted  to  a  very 
limited  distribution  of  conditions. 

By  the  author's  method  there  is 
no  need  of  such  tilting  of  the  frag- 
ments. They  can  be  drilled  and 
the  suture  can  be  passed  with  facil- 
ity in  any  position  of  the  joint, 
preferably,  of  course,  in  the  posi- 
tion of  election,  that  is,  when  the 
limb  is  extended,  and  without  in- 
terference with  the  cavity  of  the 
joint.  Again,  according  to  the 
usual  method  the  drill  hole  is  some- 
times made  unnecessarily  large 
and  so  cleared  of  tissues  as  to  ex- 
pose the  bone  to  the  risk  of  a  slight 
necrosis.  According  to  the  au- 
thor's method  the  drill  hole  need 
be  no  larger  than  to  receive  a 
suture  and  the  nutrition  of  the 
bone  need  not  be  endangered. 

The  crochet  drill  designed  by 
the  writer  for  use  in  suturing  sim- 
ple fractures  of  the  patella  is  a 
drill  with  a  slightly  enlarged  flat 


> 


Fig.  5.  —  Hand  Cro- 
chet-drill and  Fork. 
Two-thirds  of  actual 
size.  End  of  drill, 
b,  actual  size. 


112      PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS 

head.  In  the  head  of  the  drill  is  cut  a  small  notch 
only  large  enough  to  receive  a  silk  thread  (see  Fig. 
5).  The  shank  of  the  hand  drill  is  of  the  same  size 
throughout,  about  one-sixteenth  of  an  inch  in  diame- 
ter, is  spring  tempered  so  that  the  pressure  of  the 
hand  constantly  keeps  the  cutting  edge  of  the  head 
of  the  drill  at  its  work.  The  enlarged  size  of  the  head 
of  the  drill  converts  the  drill  into  a  sort  of  probe  and 
the  varying  resistance  of  the  tissues  through  which 
it  passes  can  therefore  be  differentiated.     The  head 


Fig.  6. — Use  of  Fork  in  placing  Loop  of  Silk  in  Notch  of  the 

Crochet-drill. 


of  the  drill  having  passed  through  a  fragment,  a  loop 
of  silk  is  cast  over  it  and  caught  in  the  notch  either 
by  means  of  the  tip  of  the  finger  or  by  the  specially 
designed  fork  shown  in  Fig.  6.  The  loop  of  silk  is 
then  drawn  through  the  drill  hole  by  the  withdrawal 
of  the  drill,  thus  holding  the  path  made  by  the  drill- 
ing. By  means  of  the  loop  of  silk  any  sort  of 
suture  can  be  drawn  into  position.     ( See  Fig.  2. ) 

The  hand-power  mechanism  shown  in  Plate  XIX 
jv^as  designed  to  shorten  the  time  of  drilling,  and  is 


PLATE    XIX. 

Hand-power  INIecharism  of  Crochet  Drill.     At  the  right,  the 
drill-handle   taken   apart. 


PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS      113 

especially  useful  when  the  bony  fragments  are  hard. 
The  contrivance  is  an  adaptation  of  the  Archimedean 
spiral  which  in  action  makes  the  same  number  of 
positive  and  reverse  turns,  thus  preventing  the  head 
of  the  drill  from  picking  up  shreds  of  tissue  and 
fouling.  The  mechanism  is  very  simple  in  construc- 
tion and  action.  It  is  sectionalized  and  can  be  read- 
ily assembled  without  accessory  tools.  It  is,  of  course, 
capable  of  being  perfectly  sterilized.  In  action  the 
assistant  working  the  power  stands  on  the  opposite 
side  of  the  bed  away  from  the  operator  and  the  field 
of  operation.  He  holds  the  body  of  the  mechanism 
by  his  left  hand,  firmly  pressing  the  three  legs  against 
his  breast  while  he  actuates  the  drill  by  working  the 
handle  back  and  forth  with  his  right  hand.  The  drill 
being  governed  by  the  flexible  wrist  motion  of  the 
operator  there  is  no  need  of  making  the  shank  of  the 
drill  of  spring  temper. 

Upon  trial  on  several  occasions  the  mechanism  ful- 
filled with  perfect  satisfaction  the  purposes  for  which 
it  was  designed.  It  shortened  the  time  of  drilling  the 
patella  fragments  from  several  minutes  to  a  minute 
and  a  fraction. 

To  show  the  range  in  choice  of  suture  materials 
with  the  author's  method,  he  once  drilled  two  pieces 
of  soft  pure  rubber,  each  an  inch  thick  and  accurately 
united  them  with  a  heavy  silver  wire  and  the  finest 
human  hair. 

The  author's  method  of  drilling,  therefore,  ex- 
pressed a  gain  in  scope,  preserving  its  maximum 
efficiency  under  widely  varying  distributions  of  con- 
ditions. 


114      PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS 


Fig.  7. — Drilling  of  Irregular  Fracture  of  the  Patella  while  the 
Knee-joint  is  Extended. 


Explanation  of  Figure  7. 

In  an  actual  case  "The  transverse  fracture  had  taken  a  very 
oblique  direction  through  the  thickness  of  the  bone  so  that  the 
broken  bony  surface  of  the  upper  fragment  widely  overhung  its 
cartilaginous  margin.  In  drilling  the  upper  fragment,  1,  deceived 
by  the  obliquity  of  the  fracture,  the  point  of  the  drill  was  made 
to  emerge  through  the  cancellous  tissue  some  distance  above  the 
bony  cartilaginous  junction.  As  the  lower  fragment  could  not  be 
readily  exposed,  the  drill  was  passed  directl}^  through  the  skin  and 
soft  parts  to  the  bone,  3,  its  point  emerging  through  the  under 
surface  of  the  cartilage.  It  was  clear  tliat  when  the  fragments 
would  be  wired  together  the  upper  fragment  would  be  on  a  lower 
plane  than  the  loAver  one  and  that  tlie  apposition  would  be  quite 
imperfect.  The  misdirection  of  the  hole  through  the  upper  frag- 
ment was  corrected  by  drilling  again,  2,  directing  the  drill  even  a 
little  upward  to  insure  exit  of  the  point  through  the  under  sur- 
face of  the  cartilage.  By  means  of  a  properly  constructed  instru- 
ment (the  Fork,  see  Fig.  6)  the  silk  loop  was  cast  over  the  notch 
in  the  end  of  the  drill,  which  could  be  only  reached  by  the  tip 
of  the  finger.  One  end  of  the  wire  was  drawn  through  the  upper 
fragment  and  the  other  through  the  lower  fragment  and  the  skin. 
The  drill  was  again  introduced  alongside  of  the  wire  emerging 
from  the  skin,  4,  and  passed  superficially  to  the  upper  surface  of 
the  fragment.  By  means  of  a  loop  of  silk  drawn  along  the  track  of 
the  drill,  the  wire  was  made  to  re-enter  its  opening  of  emergence 
through  the  skin  and  was  pulled  into  place."  See  original  com- 
munication by  the  author  in  the  N.  Y.  Medical  Record  of  June  7, 
1890. 


PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS      115 

The  sharp  pointed  sickle-curved  bistoury  shown 
in  Fig.  8,  was  formerly  known  as  an  abscess  knife, 
its  special  use  being  for  the  opening  of  abscesses. 
It  will  be  observed  from  its  curved  shape,  it  cannot 
be  well  aimed.  The  sharp  point  penetrating  the 
cavity  of  the  abscess  meets  with  increased  resistance 
as  it  is  pushed  onward  through  the  tissues. 


Fig.  8. — Ordinary  Curved  Bistoury,  used  for  Opening  Abscesses. 


The  abscess  knife  designed  by  the  author,  shown 
in  Fig.  9,  being  straight,  can  be  well  aimed  to  reach 
a  small  collection  of  pus  deeply  situated.  As  it  is 
pressed  onward  the  entrance  of  the  end  into  the  cav- 
ity of  the  abscess  can  be  readily  noted  because  the 
grasp  upon  the  blade  by  the  tissues  becomes  less  as 


X 


~# 


Fig.  9. — ^Author's  Design  of  Knife  for  Opening  Abscesses. 

it  advances,  since  the  cross  section  of  the  blade  les- 
sens in  approaching  the  heel.  The  knife  acts  some- 
what like  a  probe.  Turned  slightly  upon  its  long 
axis,  the  contents  of  the  cavity  ooze  along  the  side 
of  the  blade  and  disclose  their  nature,  the  blade  act- 
ing as  an  exploring  needle.  Turned  quickly  back 
into  its  original  position,  thus  keeping  the  cavity  full 


116      PEINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS 

of  contents,  the  end  of  the  blade  is  pushed  across  the 
cavity  till  it  strikes  the  inner  surface  of  the  opposite 
wall,  and  then  while  the  point  is  held  fixed  in  posi- 
tion, the  handle  is  swept  upward,  thereby  cutting 
open  the  cavity  the  desired  extent.  It  has  increased 
range  as  an  exploring  needle  and  as  a  probe.  It  ex- 
presses an  increase  in  scope. 

The  handle  of  the  scalpel  may  be  considered  from 
the  standpoint  of  scope. 

When  the  author  was  a  student,  it  was  customary 
for  the  surgeon  to  carry  his  own  instruments,  as 
needed,  from  place  to  place.  Even  the  great  Belle- 
vue  Hospital  at  that  time  had  such  a  poor  supply 
of  instruments  that  it  was  usual  for  operators  to 
provide  their  own  instruments  at  the  great  surgical 
clmics.  The  knife-handles  were  made  very  thin  in 
order  that  a  number  of  knives  might  conveniently 
be  packed  in  a  small  space  in  the  surgeon's  case.  The 
handles  were  given  their  particular  form  to  suit  the 
instrument-maker  and  not  from  surgical  reasons. 
JNIany  years  ago  the  writer  whittled  the  model  of  his 
knife-handle  into  desirable  shape.  Such  a  handle 
was  thick  and  very  nearly  octagonal  in  shape.  Since 
those  early  days  hospital  equipment  has  undergone 
a  great  change.  The  thin  flat  handle  in  development 
has  given  place  to  one  of  thickness  and  octagonal  in 
shape.  The  thin  handle  restricts  manipulation  largely 
to  wrist  motions.  The  latter  design,  while  not  ex- 
cluding wrist  motions,  allows  finger  motions  permit- 
ting the  rolling  of  the  handle  upon  its  long  axis  be- 
tween the  fingers — in  other  words  affording  a  gain  in 
scope. 


PRINCIPLES   OF  TREATMENT  OF   BROKEN   LIMBS      117 

The  patient  with  brain  injury  who  was  the  subject 
of  erysipelatous  infection  is  shown  in  Plate  XX, 
Fig.  A. 

The  six  weeks'  old  brain  sinus  with  resisting  walls 
was  easily  probed  with  an  ordinary  probe.  With  the 
recently  inflicted  wound,  however,  conditions  were 
quite  different,  and  a  surgeon  who  thought  of  using 
an  ordinary  probe  according  to  old  procedure  might 
well  have  been  pardoned  for  refraining  to  attempt 
thus  to  locate  the  bullet. 

In  further  detailed  exposition  of  the  construction 
of  his  probe  and  the  principles  of  probing  wounds 
the  author  makes  the  following  extract  from  his  con- 
tribution to  the  New  York  Medical  Journal  of 
March  28,  1885,  describing  the  successful  extraction 
of  a  pistol-ball  from  the  brain  by  a  counter-opening 
in  the  skull. 

"In  probing  a  woimd  it  is  essential  that  the  end 
of  the  exploring  instrument  shall  be  of  such  a  size 
as  not  easily  itself  to  wound  the  tissues  and  make  a 
false  passage.  The  end  should  therefore  be  large. 
Not  only  does  a  large  extremity  to  the  probe  save 
the  tissues  from  injury  and  diminish  the  chance  of 
making  a  false  passage  without  the  exercise  of  an 
undue  amount  of  force,  but  the  large  end,  even  when 
it  is  deep  beneath  the  surface  of  the  body,  is  easily 
discoverable  by  palpation  or  dissection. 

"In  probing  a  wound  to  learn  its  course,  depth  and 
other  features,  we  should  be  able  to  follow  or  infer 
with  exactness  from  the  exposed  portion  of  the  in- 
strument, the  varying  positions  of  its  buried  end.  It 
is  further  essential  therefore  that  the  end  should  hold 


118     PKINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS 


Fig.  10. 

Author's   Design 
for  a  Probe. 

Actual  size,  except 
the  length,  which 
is  twelve  inches. 


a  fixed  relation  to  the  shaft,  or,  in 
other  words,  that  the  probe  must 
have  suiRcient  rigidity  to  retain  a 
given  shape.  This  rigidity  is  requi- 
site to  the  practice  of  another  pro- 
cedure to  determine  the  location 
of  the  exploring  extremity,  namely 
conjoined  manipulation  through  the 
medium  of  the  probe.  The  shaft  of 
the  probe  should  not  only  be  rigid 
but  should  also  have  a  considerable 
bulk,  that  a  large  surface  may  be  in 
contact  with  the  fingers  and  subject 
to  the  informing  touch.  Finally,  the 
probe  fulfilling  these  requirements 
should  be  as  light  as  possible  in  order 
that  the  delicacy  of  touch  should  not 
be  lessened  in  the  exertion  to  move 
a  heavy  mass  and  that  vibrations  that 
would  otherwise  be  lost  in  the  probe 
itself  may  be  communicated  to  the 
hand. 

"The  probe  combining  these  prop- 
erties has  the  shape  (sho^\Ti  in  Fig. 
10)  and  is  made  of  tempered  alumi- 
num. The  large  end  will  generally 
pass  along  the  sinuses  connected 
with  a  wound  and  from  its  size  and 
shape  it  is  often  possible  to  tell  the 
nature  of  the  structures  with  which 
it  comes  in  contact.  It  is  only  ex- 
ceptionally that  the  smaller  end  need 


PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS      119 

be  used.  In  probing,  to  curve  the  instrument  is  to 
complicate  it  and  increase  the  chances  of  error  in 
interpreting  the  position  of  the  exploring  extremity. 

"When  the  probe  is  curved  near  the  exploring  end, 
the  other  end  of  the  shaft  should  be  bent  in  the  same 
plane  in  the  opposite  direction. 

"In  case  the  sinus  is  tortuous,  rather  than  complicate 
the  exploring  instrument  I  am  in  the  habit  of  simpli- 
fying the  wound.     Thus,  in  following  such  a  sinus 


Fig.  II. — Method  of  Probing  a  Tortuous  Sinus. 


the  end  of  the  instrument  after  it  has  passed  along 
one  curve  (Fig.  11)  should,  if  practicable,  be  brought 
toward  the  surface  and  exposed  by  careful  dissec- 
tion. The  first  curve  having  been  eliminated  the  re- 
bent  probe  can  be  introduced  through  the  new  open- 
ing at  b,  the  commencement  of  the  second  curve  bCj 
and  the  latter  explored." 

In  the  illustrative  instance  described,  the  writer  by 
his  probe  followed  the  path  of  a  pistol-ball  antero- 


120      PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS 

posteriorly  through  the  whole  length  of  the  hemi- 
sphere of  the  brain,  made  a  counter-opening  at  the 
indicated  point  on  the  opposite  side  of  the  head,  in- 
serted the  probe  in  the  new  opening,  followed  the 
ball  on  its  deflected  course  and  extracted  it,  saving 
the  patient,  who  lived  for  several  years.  (See  New 
York  Medical  Journal,  March  28,  1885.) 

It  is  proper  to  add  that  the  correctness  of  the  prin- 
ciples involved  and  the  capabilities  of  the  probe  as 
an  instrument  of  precision  were  further  confirmed  by 
two  other  instances  of  brain  injury,  the  only  other 
cases  that  came  under  the  author's  care,  and  until 
now  unpublished. 

It  is  to  be  noted  that  the  missiles  in  all  instances 
were  located  by  means  of  the  probe  alone,  no  assist- 
ance being  derived  from  radiographs.  A  single  error 
in  passing  the  probe  would  have  made  the  operation 
a  failure. 

In  one  patient  the  pistol-ball  passed  transversely 
through  the  brain  and  rebounded  from  the  inner  sur- 
face of  the  opposite  wall  of  the  skull  for  over  an  inch 
toward  the  centre  of  the  brain.  The  large  end  of 
the  probe  was  introduced  through  the  opening  of  en- 
trance. The  skull  was  opened  by  trephining  at  the 
indicated  point  on  the  opposite  side  of  the  head.  The 
probe  being  introduced  through  the  new  opening,  the 
rebounded  ball  was  traced  to  its  place  of  lodgment, 
about  one-third  way  toward  the  centre  of  the  brain, 
and  felt  on  the  side  of  the  wall  of  its  initial  path 
through  the  brain.  The  head  was  so  placed  that  the 
principal  path  of  the  ball  was  perpendicular  to  the 
horizon.    With  the  large  end  of  the  probe  introduced 


PLATE    XX. 

A.  Upper  Figure. — Pistol-shot  Wound  of  the  Brain,  Six 
Weeks  since  Injury.  The  brain- wound  had  become  a  discharging 
sinus  with  walls  of  some  resistance.  The  ball,  lodged  near  the 
centre  of  the  brain,  was  encysted.  The  sinus  was  followed  by 
an  ordinary  probe  which  could  not  have  been  done  in  the  fresh 
wound. 

Lower  Figure. — Shows  the  course  of  the  probe  to  the  con- 
tact with  the  ball. 

B.  Upper  Figure. — Straight  Course  Antero-posteriorly  of  a 
Ball  to  the  point  of  Contact  on  Inner  Surface  of  the  Opposite 
Side  of  the  Skull.  Very  troublesome  hemorrhage  of  a  branch  of 
the  artery  of  the  corpus  callosum,  shown  in  E,  lower  figure,  was 
stopped.  The  ball  was  then  tracked  with  a  large  probe  to  its 
point  of  contact  with  the  opposite  side  of  the  skull.  Judging 
from  the  exposed  portion  of  the  straight  probe  the  concealed  end 
of  the  probe  was  opened  upon  by  a  trephine  at  the  indicated 
point  upon  the  opposite  side  of  the  head.  The  probe  was  en- 
tered at  the  new  opening  and  the  deflected  path  of  the  ball  was 
followed  till  the  ball  was  reached  and  removed. 

Lower  Figure. — Shows  the  course  of  the  path  of  the  ball 
through  the  hemisphere. 

C.  Upper  Figure. — Opening  of  Entrance  of  a  Pistol-ball  Be- 
hind the  Right  Ear. 

Lower  Figure. — Shows  the  Course  of  the  Ball,  Inward,  Up- 
ward and  Forward.  Path  of  the  ball  explored  by  the  large  probe 
and  place  of  lodgment  of  the  ball  established  by  contact  with 
the  probe.  The  author  introduced  his  left  index  finger  its  full 
depth,  felt  the  ball  and  with  uterine  tenaculmn  hooked  the  ball 
against  tip  of  the  finger  and  removed  it. 

D.  Upper  Figure. — Point  of  Entrance  of  Pistol-ball. 

Lower  Figure. — Dotted  Line  Indicates  Course  of  Ball  Trans- 
versely Across  the  Brain  to  Place  of  Contact  with  the  Inner  Wall 
of  the  Opposite  Side  of  the  Skull.  Skull  opened  at  indicated 
point  by  small  trephine  hole,  probe  introduced  at  new  opening 
and  the  rebounded  ball  traced  to  its  place  of  lodgment  half  way 
toward  the  centre  of  the  brain. 

E.  Upper  Figure. — Median  Section  of  the  Head  showing 
Falx  Cerebri  in  Position  and  Point  Probably  Pierced  by  the  Ball 
in  its  Course  Across  the  Head  in  Figure  D. 

Lower  Figure. — The  Inner  Face  of  the  Hemisphere  After 
the  Falx  was  Removed.  Branches  of  the  artery  of  the  corpus 
caUosum  may  be  seen. 


PRINCIPLES    OF   TREATMENT    OF    BROKEN    LIMBS      121 

into  the  opening  of  entrance  the  ball  was  gently  urged 
downward  by  the  probe  till  it  could  be  felt  against 
the  tip  of  the  finger  watching  at  the  counter  opening, 
and  was  then  extracted  (see  Plate  XX,  Fig.  D). 

The  head  was  replaced  in  normal  position  and 
the  probe  reintroduced  transversely  into  the  brain. 
When  the  large  end  was  half  way  through  the  brain 
its  progress  was  checked  by  a  soft  but  distinctly  felt 
resistance.  Presently  the  brain  was  felt  to  move 
slightly  and  the  probe  was  then  passed  easily  on- 
ward through  the  head.  To  the  smaller  end  of  the 
probe  were  attached  five  or  six  strands  of  small-sized 
catgut,  which  were  drawn  through  the  brain  to  act 
as  a  drain. 

Upon  careful  after-study  it  was  established  that 
the  ball  had  passed  through  the  falx  cerebri  (see 
Plate  XX,  upper  figure,  E).  Without  doubt  in 
passing  the  probe  transversely  through  the  head  the 
large  end  was  halted  against  the  edge  of  the  opening 
through  the  falx,  but  upon  the  slight  movement  of 
the  brain  that  opening  was  centred.  The  patient 
recovered  and  lived  for  more  than  five  years. 

In  the  third  patient  the  pistol-ball  entered  behind 
the  upper  portion  of  the  right  ear,  pushing  frag- 
ments of  bone  before  it.  The  patient  displayed  no 
nervous  symptoms  to  guide,  and  there  was  much  dis- 
cussion as  to  the  course  of  the  ball.  The  probe  re- 
vealed that  it  had  passed  inward,  forward  and  up- 
ward. It  was  so  much  flattened  that  it  could  not  be 
grasped  with  the  bullet-forceps.  The  writer  then 
passed  his  left  index  finger  its  full  length  into  the 
brain  and  felt  the  ball  at  the  tip  end  of  the  finger. 


122      PRINCIPLES   OF   TREATMENT   OF   BROKEN   LIMBS 

By  sliding  a  delicate  uterine  tenaculum  along  the 
finger  he  hooked  the  ball  against  the  tip  of  the  finger 
and  extracted  it.  Hemiplegia  of  the  opposite  side 
set  in  immediately,  but  wholly  cleared  up  in  twenty- 
four  hours.  The  patient  recovered  and  lived  more 
than  two  years  (see  Plate  XX,  Figure  C). 

No  test  for  probing  a  wound  in  soft  tissue  could 
have  been  severer  than  those  imposed  in  these  three 
patients.  It  showed  the  extreme  range  of  probing 
through  paths  of  wounds  with  delicate  walls. 

The  educated  touch,  the  "tactus  eruditus/^  is  an  ex- 
tension of  scope  in  manipulation.  No  illustrative  in- 
stances are  needed  to  emphasize  its  great  importance. 

In  all  fields,  scope  as  a  measure  of  value  is  acknowl- 
edged. The  smaller  range  in  scope  is  always  at  the 
mercy  of  the  larger  range.  In  final  analysis  all  such 
increases  in  scope  are  resolvable  into  increases  in 
responses.  To  pass  from  lesser  to  greater  scope, 
is  progress;  to  pass  from  greater  to  lesser  scope,  is 
regress. 


INDEX 


Abscess-knife,  author's  design,  115. 

Absolute  immobility,  unattainable  with  extrinsic  splints,  54. 

Absorbent  dressings,  discarded,  52 ;  upon  septic  wounds,  102. 

Adjustment  of  bony  fragments,  9. 

Affirmative  instance  destructive  to  negative  assertion,  92. 

Ambiguous  term,  2;    plaster-of-Paris  splint  as,  62. 

Amputation  of  the  thigh,  treatment  of,  103;  dressing  of,  while  asleep, 

104. 
Amputation  of  the  thigh  and  forearm,  in  physical  rest,  102;  in  extended 

functioning,  108. 
Antiseptic  measures,  effect  upon,  compound  fractures,  53,  73;  should  be 

standardized,  87;  defective,  87. 

Bandage,  first  layer  of,  13;  second  layer  of,  14. 

Bandaging,  part  of  soldier's  training,  8;  secundum  artem,  11;  practical 
skill  in,  12;  traumatic  gangrene  from  tight,  8;  compression  of 
tissues,  13;  tactus  eruditus,  13;  figure  of  eight  reverses,  14;  grad- 
uated support  of  the  circulation,  41. 

"Begging  the  question,"  3,  108. 

Bellevue  Hospital,  septic  saturation,  12,  52,  53,  79,  81,  82,  83,  84,  86, 
116;  medical  board  of,  83,  84,  86. 

Bistoury,  sickle-curved,  115. 

Brain,  probing  of,  120. 

Brain  sinus,  79;    resisting  walls,  117. 

Bridge  or  truss,  construction  of,  91. 

Burden  of  proof,  96,  97. 

Categories,  creation  and  definition,  77;  multiplication  of  instances  in, 
77;  difficulty  of  determining  and  defining,  78;  of  exceptions  of 
non-operative  treatment,  96;  subject  of  negative  assertion,  92. 

Categories  of  responses,  76. 

Clove-hitch,  33. 

Coarse  motion,  range  of,  55;  normal  may  be  exceeded,  56;  affected  by 
suspension  apparatus,  74. 

Commissioners  of  Public  Charities  and  Correction,  4. 

Comparison  of  the  value  of  methods  of  treatment,  76. 

Compression  of  soft  parts,  47. 

Compound  fractures,  regarded  as  infected,  16;  protective  covering  of,  16; 
Lister's  bandages  for,  17;  antiseptic  gauze  about  the  wound,  17; 
sterile  dressings,  17;  plaster-of-Paris  splint  discarded  in  treatment 
of,  72;  eff'ect  of  antiseptic  treatment  on,  73;  bridge  or  truss  to 
hold  fragments,  91;  treated  in  fracture-box,  105;  treated  upon 
sectional  supports,  105;  without  dressings  upon  wound,  105;  in 
category  allied  to  simple  fractures,  107;    iron  staples,  91. 

Compound  pulleys,  19,  23,  29,  38,  40. 

123 


124s  INDEX 

Conjoined  manipulation  through  medium  of  probe,  118, 

Consensus  of  opinion,  58. 

Constructive  field  of  the  mind,  58. 

Counter-extension,  18,  20,  99. 

Criterion  of  value,  1,  77,  78;    of  excellence,  76. 

Crochet-drill,  an  example  of  increase  of  scope,  110;    description  of,  111; 

notch  in  head  of^  112;    as  a  probe,  112;    hand-mechanism  of,  113; 

drilling  and  suturing  of  soft  rubber,  113,  116. 

Diagrammatic  representation  of  truss,  5. 

Disturbance  of  broken  limb,  10. 

Double  amputation,  Syme  and  Stephen  Smith,  105. 

Drainage  in  compound  fractures,  16. 

Drilling  of  irregidar  fracture  of  the  patella,  114. 

Elastic  suspension,  66. 

Elective  period  of  applying  thigh  splint,  24. 

Empiricism,  results  of,  1 ;    social  organism  in  region  of,  59. 

Erysipelas,  in  Bellevue  Hospital,  69,  80;    affecting  brain  wound,  80; 

cause  of  infection  of  brain  wound,  80. 
Essential  attribute  of  treatment,  54;    is  a  mechanical  one,  55;    measure 

of  its  value,  55. 
Essential  and  non-essential  attributes,  generalized,  58. 
Essential  factor,   influence  of  methods   of  treatment  upon,  62;     as  a 

functioning  variable,  62;    extension  of  functioning,  64. 
Extreme  range  of  probing  wounds  with  delicate  walls,  122. 

Fallacies,  drawn  from  bad  results,  98. 

Falx  cerebri,  pistol-ball  passed  through,  121. 

Fenestrse  in  plaster-of-Paris  splint,  52. 

Figure  of  eight  reverses  of  bandage,  12. 

First  line  of  defense  of  wounds,  86. 

Foot,  immobilization  at  right  angle  with  leg,  41. 

Foot  and  leg,  splint  constructed  upon,  before  making  thigh  splint,  41. 

Fork,  111,  112,  114. 

Fracture  of  both  thighs,  suspension  apparatus,  46;  increase  of  coarse 
motion  by  suspension,  74;    open  operation,  97. 

Fracture-box,  restriction  of  surgical  relations,  67 ;  compound  fracture  of 
the  leg  treated  in,  105. 

Fracture  of  the  shaft  of  the  femur,  evolution  of  apparatus,  18;  author's 
apparatus,  20;  perineal-bar,  21 ;  time  of  setting,  22 ;  long-existing 
shortening,  23 ;  splint  exerts  extension  and  counter-extension,  23 ; 
elective  time  of  applying  splint,  24;  measurement  of  shortening, 
25;  personal  error  in  measuring,  25;  protection  of  limb  during 
an£Esthesia,  26;  covering  limb  with  blanket  protective,  27;  covering 
of  the  foot,  29;  assistant  controls  fragments,  29;  ground  plan  of 
position  of  patient,  30 ;  fixed  points  of  extension  and  counter-exten- 
sion, 30;  duties  of  principal  assistant,  31;  leverage  upon  upper 
fragment,  31;  duties  of  anaesthetizer,  32;  purpose  of  pelvic  wire, 
32;  fixed  point  of  extension,  32;  review  of  steps  of  procedure,  34; 
temporary  extension,  35;  details  of  construction  of  plaster-of-Paris 
splint,  35 ;  pelvic  portion  of  splint,  36 ;  reinforcement  of  splint,  36 ; 
placing  of  tin  strips  in  position,  37;  full  degree  of  extension,  38; 
strengthening  of  splint,  39;  finishing  coat  of  splint,  40;  removal 
of  clove-hitch,  40;    places  exposed  to  undue  pressure,  41;   freeing 


INDEX  125 

patient  from  apparatus,  42;  care  of  splint  after  it  has  set,  42; 
care  of  tissues  of  perineum,  43;  subjective  realization  of  union  of 
fragments,  43;  removal  of  splint,  44;  shortening  in  limb  after 
treatment,  45;  stiffness  of  joints,  45;  non-union,  46;  specimen 
of,  93,  94. 

Fracture  of  shaft  of  the  femur,  categories  of,  96 ;  sub-trochanteric  frac- 
ture of  the  femur,  98;  logical  bearing  of  result  of  treatment  upon 
assertion  of  a  negative,  101. 

Fracture  of  both  bones  of  the  leg,  4;  in  a  woman,  60;  analysis  of  con- 
sequences, 61. 

Fragments,  speedy  fixation  of,  3;  impossibility  of  holding  immobile, 
5,  6;    initial  fixation  of,  11. 

Frame,  covering  of,  103. 

Function,  signification  not  arbitrarily  limited,  67. 

Gangrene,  traumatic,  17,  18. 

Generalization,  74. 

Guides  for  adjustment  of  fragments,  9. 

Hamilton,  Professor  Frank  H.,  4, 
Handle  of  scalpel  from  standpoint  of  scope,  116. 
Hand-power  mechanism  for  drilling  patella,  112. 
House  Staff,  13,  60;    Ninety-ninth  Street  Hospital,  85. 
House  surgeon,  19,  61. 

Humerus,  tin  strips  in  fracture  of,  18;  dangers  of  immovable  splint,  18; 
traumatic  gangrene,  18. 

Impersonal  proof  of  values,  58,  101. 

Impersonal  truth,  58. 

Incident  forces,  modified  by  suspension  apparatus,  65. 

Inclusion  of  foot  and  ankle  in  thigh  splint,  41. 

Increased  scope  illustrated  by  crochet  drill,  110. 

Inseparable  accidents  or  characteristics,  57,  66,  75. 

Interposition  of  tissue  in  fractures,  95. 

Intrinsic  appliances,  motive  for  use,  90. 

Iron  staples,  used  in  compound  fractures,  91. 

Knife-handles,  why  made  thin,  116;   example  of  scope,  116. 

Lister's  bandages,  7,  17. 

Logical  expressions,  use  of,  2. 

Loss  of  blood,  in  septic  patients,  102. 

Maintained  immobility  of  fragments,  54;    under  extension,  74. 

Malarial  poison,  causative  factor  of  septicaemia,  86;    quinine,  86, 

Measure,  of  quality,  75;    of  value,  122. 

Measurement  of  shortening  of  leg,  11. 

Medical  Board  of  Bellevue  Hospital,  83. 

Military  practice,  thigh  setting  apparatus,  20. 

Military  training,  in  bandaging,  8. 

Methods  of  treatment,  therapeutic  influence,  57. 

Missiles  in  the  brain,  located  by  probe  alone,  120. 

Negative  assertion,  90,  92,  97,  98. 
New  York  Medical  Journal,  117,  120. 


126  INDEX 

New  York  Medical  Record,  89,  114. 

Ninety-ninth  Street  Reception  Hospital,  84;    aepticsemia,  85;    malarial 

poison,  85,  88;    out-patient  service,  85. 
Non-union  of  fractures,  71. 

Oakum  dressing,  109. 

Objection  to  the  plaster-of-Paria  splint,  94. 

Observation  of  facts,  2. 

Obsolete  procedures,  2. 

(Edema,  rendering  splint  eflFective,  44. 

Open  operation  in  treatment  of  simple  fractures,  90,  95;    as  a  routine 

measure,  96;    may  be  advisable,  96;    not  of  necessity,  100. 
Organization  of  phenomena,  58. 
Osteophyte,  93. 
Outline  of  limb,  guide  to  setting  fracture,  reverses  of  bandage  away 

from,  12. 
Overcrowded  wards,  82. 

Padding  of  Cotton,  10. 

Park  Hospital,  83,  84,  86,  88. 

Pearson,  Prof.  Karl,  58. 

Pelvic  portion  of  plaster-of-Paris  thigh  splints,  36. 

Perineal  bar,  19,  20,  21,  31,  32,  46. 

Permanent  splint,  material  in  construction  of,  7. 

Personal  authority,  58. 

Personal  error  in  measuring,  25. 

Phenomena,  organization  of,  58. 

Pistol-ball  in  brain,  120,  121. 

Plaster-of-Paris  bandages,  11,  12. 

Plaster-of-Paris  splint,  5;  truss  in,  6;  strengthening  of,  15;  finishing 
construction  of,  16;  an  ambiguous  term,  62;  connotes  variety  of 
resistances,  63;  resistance  varies  with  recession  of  swelling,  63; 
restrictive  of  functioning  of  tissues,  67;  therapeutic  influence,  68;' 
deleterious  influence  over  the  union  of  the  bony  fragments,  69,  70; 
essential  and  non-essential  attributes,  71 ;  beneficial  influence  in 
early  stages  of  application,  72;  discarded  in  the  treatment  of 
compound  fractures,  72. 

Plating  fragments  of  bone,  99. 

Pott's  fracture,  4,  17. 

Practical  immobility  distinguished  from  absolute  immobility,  54;  dis- 
turbance of,  54;  factor  of  safety  in  preserving,  54;  niaintenance 
of,  55. 

Probe,  construction  of  author's,  118;  conjoined  manipulation  by  means 
of,  118. 

Probing  of  wounds,  principles,  117;  of  tortuous  sinus,  119;  of  brain, 
antero-posteriorly,  120;    transversely,  120. 

Progress,  122. 

Protective  covering  material,  9,  10,  13,  28. 

Quality,  measure  of,  75. 
Quinine,  86,  88. 

Recapitulation,  regarding  restriction  of  function,  68. 
Reductio  ad  absurdum,  95. 


INDEX  127 

Regress,  122. 

Relative  values,  determination  of,  2. 

Responses,  75 ;    varying,  57;    comparative  value  of,  58,  67;    expressive 

of  continuous  adjustments  of  the  organism,  75. 
Restriction  of  functioning  of  tissues,  fracture-box,  side  splints  and  plas- 

ter-of-Paris  splint,  67. 
Results  of  treatment,  in  their  effects,  76;    in  elements  of  dissimilarity, 
101;    arbitrary  limitation  of,  56;    as  effects,  56,  57. 

Sayre,  Prof.  Lewis,  A.,  4. 

Scope,  110;  in  speed  of  immobilization.  110;  illustrated  by  crochet 
drill,  110;  illustrated  by  abscess-knife,  115;  illustrated  by  handle 
of  scalpel,  116;    illustrated  by  probe,  117,  118. 

Second  line  of  defense  of  wounds,  87. 

Sectional  supports,  105,  106,  107. 

Scientific  exactitude,  59. 

Self-abnegation,  acts  of,  59. 

Separable  accidents,  59. 

Sepsis,  antiseptic  measures  competent  to  prevent,  53,  81,  82. 

Sepsis,  modification  of  incident  cause,  88. 

Septic  patients,  loss  of  blood,  102. 

Septic  Saturation  of  Bellevue  Hospital  in  Early  Seventies,  79. 

Septicaemia,  in  Bellevue  Hospital,  82;  in  Ninety-ninth  Street  Hospi- 
tal, 86. 

Shortening  of  broken  femur,  25. 

Side  splints,  67. 

Silver  wire,  113. 

Sinus  of  brain,  79. 

Skill,  2,  12,  94,  98;    errors  of,  12. 

Social  organism,  59,  77,  101. 

Soldiers,  7,  8. 

Specimen  of  oblique  fracture  of  the  femur,  43. 

Spencer's  definition  of  life,  75. 

Stephen  Smith  side  flap  amputation  of  the  leg,  105. 

Sterile  dressings,  17. 

Stiffness  of  joints,  45. 

Sub-trochanteric  fracture  of  the  femur,  98. 

Summing  up,  78. 

Surgeon,  engaged  in  defining  categories,  76. 

Surgical  functioning,  105,  108. 

Suspension  apparatus,  fracture  of  both  thighs,  46;  principles  embodied 
in,  47;  primitive,  48;  Dr.  Van  Wagenen's,  48;  author's,  48;  ele- 
vation of  limb  in,  51,  66;  extension  of  function  of  essential  factor, 
64;  evolution  of,  in  Bellevue  Hospital,  64;  incident  forces  modified 
by,  65;  vertical  position  in,  66;  from  a  single  point,  66;  infiuence 
upon  coarse  motion,  74. 

Suturing  of  recent  simple  fractures  of  the  patella,  89. 

Swelling.  10,  22,  24,  25,  63. 

Syllogistic  form,  78. 

Syme's  amputation  at  the  ankle-joint,   105. 

Tactus  eruditus,  13,  81,  122. 
Theoretical  maximum  of  excellence,  57. 
Therapeutic  influence  of  plaster-of-Paris  splint,  68. 
Thigh,  primary  amputation  of,   108. 


128  INDEX 

Time  element,  7. 

Tin  strips,  immediately  effective,  6;  in  civil  practice,  7;  in  military 
practice,  7;  are  the  splint,  9;  an  example  of  scope,  116;  dispense 
with  water  and  plaster-of-Paris,  8;  details  of  construction,  8;  use 
in  fractures  of  the  leg,  14;    uncontrolled,  38,  39. 

Toes,  tell-tale  of  the  circulation,  16;    covered  by  splint,  12,  42. 

Tortuous  sinus,  probing  of,  119. 

Traumatic  gangrene,  18. 

Treatment  of  septic  wound  complications,  compound  fractures  and  pri- 
mary amputations,  102. 

Truss,  surface  member  of,  4,  5;    diagrammatic  representation  of,  6. 

Values,  attach  to  results,  2. 
Vertical  suspension,  66. 
Visiting  Staff  of  Bellevue  Hospital,  3. 
Visiting  Surgeon,  60,  61,  86. 
Volkmann's  apparatus,  99. 

Wasted  energy,  109. 
Wire  frame,  103,  104. 
World's  Fair  of  1873,  4. 
Wound,  first  line  of  defense,  86. 


'  6 


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COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RD  101  F67  C.I 

An  inquiry  into  thf  ofmrinips  of  Ireatm 


2002110474 


T-tJ  T 


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